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! APPLICATION FOR PERMIT 476 _. <br /> i I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV IRONUgNfA;L�HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> , . P 0 BOX 2009, STOCKTON, CA 95201 <br /> JUN 9 1596 <br /> REMIT EXPIRES 1 YEAR FROM DATE ISEUM <br /> I"NVIRONMENTALHi=ALP- (Complete in Triplicate) <br /> Applicati%WEW ,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> i application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services[,---, r�y ./} ' <br /> Job Address r� Cit �`�_` t Size/Acreage <br /> r ] <br /> Address 51340�jt leirl- — _ Phone �`• <br /> Owner's Name jy� <br /> O ' <br /> Contractor aAddress <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR O OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IF] Ind strias ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X".'estic/Private ❑ Gravel Pack ; L7 Tracy Type of Casing Specifications <br /> F1 Public 1.1 Other t n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigat=ion.W_ Approx. Dept 1 1 stern Sur ce Sal Installed by 42 4 <br /> i <br /> Repair Work Done [i9' Type of Pump � H.P, State Work Done <br /> Well Destruction ❑' Weil Diameter 4 Sealing Ma rial & Depth <br /> Filler Material & Depth ' 11 <br /> rya,- V - Depth.I f V� <br /> TYPE OFS£PTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is U7 <br /> ¢ j -1 t � f ; available within 200 feet.] <br /> Installation will se e: Residence Commercial Other �/� <br /> 1 y 1 V r <br /> Number of living units: NO nber of:bedroems�``� ` � J <br /> Character�of soil to a depth of 3 feet: l Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg ! ! • Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ � � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> z <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth f Size Number <br /> SUMPS UI Distance to nearest: Well Foundation . Property Line <br /> DISPOSAL PONDS C] <br /> I hereby certify th ave pr ared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I rules and reg tons of the 5a Joaquin Co <br /> Home own or licensed agent' si ature ce ifl s the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> #, employ a person in suc nn t be m subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifie he following: "I if t n rt mance Oftha wor ich thpermit is issued, I shall employ persons subject to workman's compensa- <br /> tion I s of Ca'forni <br /> The pplicant s for i tions Complete drawing o e side. <br /> Sign d Title: Date: <br /> r <br /> FOR P TMENT USE ONLY <br /> Application Accepted by Date Area <br /> I Pit or Grout Inspection by Date Final Inspection by. Data q-7.6-15 <br /> ..p <br /> Additional Comments: \ <br /> Applicant — Return all, copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Dox 2009, Stockton, CA 95201 <br /> i 11 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> i 1r <br /> EK A-2�TREY.1rH51 { G 19C) <br /> -1k _C7 S <br /> EH i�2B L <br />