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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONJIENTAL HEALTH DIVISION <br /> 445pN0SAN <br /> OAQ9INSTpOCKTON,HONE CA,95201420 •. <br /> PERM EXPIRES I. YE FR M _D TE SU <br /> (Complete in Triplicate) <br /> work <br /> in <br /> Application in hereby made.to Ban Joaquin CountoCom OrditrlancenHo51+9 andstruct o1862sand thatall eliulea sndeRegulationsdof San <br /> $ <br /> pp <br /> application is made in compliance with Ban Joaquin41Joaquin County Public Health Services. <br /> City Lot Size/Acreage i <br /> Job Address <br /> 1 Phone <br /> Address <br /> is Name I Q�;� g2A_3 <br /> �� Liicense No. V-'1 k Phone <br /> 'Contractor ss E ENT ❑ DESTRUCTION ❑ Out of Service We]111 ❑ <br /> NEW W WELL REPLACE s � Monitoring We ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAi?+ OTHER ❑ <br /> PUMP INSTALLATIO <br /> SEWER LINES — DI POSAL FLD. PROP. LINEI <br /> DISTANCE TO NEAREST: SEPTIC TANK __ � OTHER WEIL T, PITS/SUMPS <br /> FOUNDATION - AGRICULTURE WELL 1 <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECif�ICATIONS. Dia. of Well Casing <br /> Dia. of Wall Excavation <br /> ❑ duatrial ❑ Open Bottom ❑ Manteca'° Specifications <br /> I, 4 <br /> �° ❑ Tracy s Type of Casing- <br /> Domestic!Private ❑ Gravel Pat; Type of Grout` <br /> (_� Other fl Delta Depth of Grout Seal <br /> I'I Public Surface Seal Installed by <br /> Approx. Dep l Ea tern <br /> I I Irrigation ;H P State Work Dona <br /> Repair Work Done O Type of Pum Material 4 Depth <br /> 1 Sealing- <br /> 1 Well Destruction ❑ Well Diameter �..� !'filler'Hater La A Depth ' <br /> Depth <br /> ! available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIRIADUITION I S DESTRUCTION i I (Noave septic system permitted it public sewer is <br /> Installation will serve: ' Residence_;_ Commercial Other's' <br /> Number of living units: Number of bedrooms gim <br /> e depth fCharacter of so4 to a depth of 3 feats Capacity artmentsSEPTIC TANK ❑ -Type/Mfg Disposal PKG. TREATMENT PLT.❑ �-.Foundation Pr .- "Distance to nearest: Well �'�_ _,7—Total lengLEACHING LINE ❑ No-*-Length of tineaPrFILTER BED ❑ Distance to nearest: Well T---- ,f,oundationNumberSEEPAGE PITS 11 Depth _ Size Foundation P <br /> SUMPS LI Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> 1 hereby cenify that I have prepared this application and that the work willbe done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County g: „ <br /> Home owner or licensed agent's signature certifies the folVowin I certify that in the performance of the work for which this ring rsrmit.is issued, I shall nae <br /> Iowa of California."Contractof' <br /> employ any person in,such <br /> manner n to t performance <br /> man ecof the work t to w ork afor which this tnPermitissued,I shall employ persons rsubj ct to worktman�s compensa- <br /> I certifies the foMo ng <br /> tion laws opr.,allfornla." , <br /> The a n !st call f a1 u'ed ins tions. Complete drawing on rev r side. <br /> Title: <br /> kzi Date: <br /> . #� <br /> Signed -,,,- <br /> R DEPARTMENT USE ONLY <br /> s ~ <br /> Date` D Area <br /> Application Accepted by - <br /> Nf Date <br /> Date�-- Final Inspection by <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: EnvironmentalJoaquin oHealth umity ublic Health vices <br /> Permit/Services ` <br /> 445 N San Joaqu O Sox 2009, Stkn, OA 95201 <br /> KRECEIVED Y D TE PERMIT*NO. <br /> FEE AMOUNT DUE AMOUNT REMITTE ASH <br /> INFO <br /> . EN13-24(REV:lin5) t"f�r0-0 <br /> EN 14.711 <br />