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r � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 i <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> p T EXPIRES <br /> YAR FROUEU <br /> D T sugg <br /> � . .. <br /> (Colnpl®,Ve in Tripiicate)� ;.. <br /> This <br /> Application is hereby.made;to"SaarJoaquin County. for a permit to construct and/or install the Work herein described. <br /> 11cn-coovhiance-vesh $en Joaquin -Coun <br /> tyrOrdinance No. 51+9 and 1862-and-the Rules and Regulations of.San <br /> application is � <br /> Joaquin County Pub <br /> City Lot-Size/Acreage <br /> _ 1 k-wfz ' <br /> Job Address <br /> J$'l'E ._ r _Phone <br /> Owner's Name /7TA��J / / Address yy <br /> �' t �� Phone 71 <br /> f Address' f 2.'1 � !_ � —L-icen-se No. <br /> Contractor DESTRUCTION Out of Service well ❑ <br /> NEW WELL,Q�,, WELL REPLACEMENT ❑ Monitoring Well ❑ <br /> TYPE Of WELL/PUMP: t.- \, „ AOTHER ❑ <br /> } e <br /> PUMP.INSTALL INSTALLATION O . -+ SYSTEM REPAIR.❑'a < <br /> �` DISPOSAL FLD. - PROP. LINE <br /> Z SEWER_LINES <br /> DISTANCE TO TO NEAREST: SEPTIC TANK _�_ �- - - PITS/SUMPS <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL_ <br /> 4 <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS + <br /> INTENDED USE ,_TYPE Of WELL,., Ois. of Well Casing <br /> 0 Industrial ❑ Open Bottom- "'°, <br /> ❑ Manteca Dia. of Well Excavation <br /> Type g Specifications 7 <br /> [l Doisiestic/Privy"te h ±❑NGrayel Packer-�`y� C7 Tracy Depth of Grout Seal""'"- Typerof'Grout <br /> f'3 Public (-1 Other [� Della + //�� 1!f• <br /> k ...y n` � I 1 <br /> �I I Initiation w Approx. Depth l I Eastern Surface Seal Installed by <br /> r H.P. <br /> State Work Done ��� <br /> Repair Work Done U Type of Pump T ^ <br /> Material i Depth <br /> Weil Destruction Well Diarr ester Sealing <br /> De <br /> .pthh.``cam` ' ., � �' '� filler Material a Depth , <br /> - ` , <br /> TYPE OF SEPTIC WORK: ANEW INSTALLATION I i REPAIRlADDITION I I ESTRUCT10N l I INa septic system permitted i public sewer is <br /> ;� available within 200 feet.) <br /> � A&i;w <br /> } Installation will serve: Residence.— Commercial ;,z Other —�I ���//�' FIAA 7X&A-f/ <br /> ­% X <br /> Number of living unite:' Number of bedrooms <br /> Water fable 6apth <br /> Character of toll to a depth oi'3'feet: r T No.,Compartmenu _-�-- <br /> SEPTIC TANK (0 Type!Mfg Capacity p` 1 <br /> `Method of Disposal <br /> PKG.. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation Properly Line �— <br /> k r� t <br /> Total Iengih/size <br /> LEACHING LINE L1No. S Length of lines <br /> """----""�-�""' Foundation r Property Line <br /> FILTER BED D Distance to nearest: Well _ l t <br /> C� <br /> - <br /> ¢ SEEPAGE PITS I I Depth . � �j ���� Size Number � <br /> r ' s Foundation Property Line <br /> .— <br /> SUMPS UI Distance to rwsr. Well t <br /> . <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coun'ty ordinances, state laws, and <br /> rules and regulations of the San Joaquin County , 111 <br /> i Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit,is issued, I shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to.workman's compensa <br /> tion laws of California." ... n. , �" � <br /> The applicant at drawing on reverse 'de. <br /> Title: � Date: <br /> Signed - 1R' r<, <br /> 0R- EPARTMENIT USE 0111LYi'I- " <br /> Data Area Z <br /> Application Accepted by <br /> Date <br /> Pit or Grout Impaction byJ'� Data T Final Inspection by e <br /> �_Additionii Comments: , <br /> Applicant - Return all copies to: San Joaquin County'Public Health Services <br /> 1 Enviroumen'tal•=Health-Permit/Services <br /> R.:... <br /> 4415-if San Joaquin, P 0 8662009-, StkntyCA 95201 <br /> FEE AMOUNT DUE- !A-MOUNT REMITTED > CK RECEIVE BY''S DATE WPERMI-CNO. <br /> INFO <br /> . EYS'1Ft�-iRtEV.-�i n-a1 - <br /> EH i4-M - <br />