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APPLICATION FOR PERMIT <br /> SAN 30AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ` ENVIRONMENTAL HEALTH DIVISIONS ' <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201_ <br /> PH ITXP RES 1 YEAR ERM DA E ISSUM <br /> (Complete in Triplicate) <br /> t to construct and/or install <br /> Application is hereby made to Sen Joaquin County for a permithe work herein described. This <br /> application is made in compliance with San Joaquin County Or No. 5b9 and 1662 and the Rules and Regulations of San <br /> I Joaquin County Public Health Services. <br /> fr City Lot Size/Acreage <br /> lei Jots Address C� <br /> Owner's Name <br /> rcAddress Phone <br /> Contractor Address <br /> (� . (�C License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPi_ACEMENT 0 DESTRUCTION 0 Out of Service Well L"1 <br /> '� Monitoring Well' <br /> SYSTEM REPAIR L-01 <br /> "`� OTHER 0 , <br /> PUMP INSTALLATION Q _ <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> i DISTANCE TO NEAREST: SEPTIC TANKS PiTSISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL+�ROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f� Industrial. . Xo � Open Bottom D Manteca _ Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications <br /> FI Domestic I Private 0 Gravel Pack ❑ Tracy yP g �,�«_.._,--- Type of-Grout k� <br /> '' I'f Public f fa Other f� Delta ,;tiDePth of Grout Seal ' <br /> �. I I Irritation l�Eastem""Surface Seal Installed by <br /> �l f -_ <br /> H P State Work-Done, <br /> Repair Work Done L7 Type of Pump t <br /> Sealing Material & Depth <br /> Weil Destruction O Well Diameter m Filler Material & Depth <br /> Depth e� <br /> TRUCTION I 1 ublic sewer is \ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1. REPAIR/ADDITION [No septic system permitted if pavailable within 200 feet.) <br /> Installation will serve:- Resi nce Commercial—L—t—her (� <br /> Number of living units: Number�of bedrooms f <br /> Character of soil-to-a_depth of 3 feet: C Water table depth <br /> I . <br /> Capacity No. Compartments <br /> SEPTIC TANKO Type/Mfg p <br /> F PKG, TREATMENT PLT-0 t Method of Disposal <br /> 4 distance t serest: ., Well Foundation Property Line , <br /> LEACHING LINE P-17757& Length of,lines � Total lengthIsize `S r <br /> E v <br /> FILTER SED ❑ Distance to'nearest:. Weil._�- Foundation ���r Property Line — <br /> i SEEPAGE PITS L--Oupth Size N�be <br /> r <br /> i SUMPS LI Distance to nearest: Welt Foundation Property Line <br /> l DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> t 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 /> f employ any person 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: '1 certify that in the performanca of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tio laws of California " <br /> The apple t st call f all squire ins omptete drawing on averse side. t <br /> Sign Title: _ Date: <br /> 7 IJ-7 <br /> 4.+ R DEPARTMENT U5E <br /> Date— <br /> Pit <br /> Area <br /> Application Accepted by - <br /> � <br /> Pit or Grout Inspection by Date-' Final Inspection by ate <br /> a <br /> \\ 1, <br /> Additional Comments: <br /> Wilk <br /> Applicant - Return co o: oaqu y_ ealth_ ^�- <br /> .,,,I$ervices;Environmental Health Permit/Services <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> E FEEEE) E AM6uNT REMITTED _ CASH____ _CK RECEIVED BY DATE PERMIT'NO. <br /> INFO i �i <br /> I a EH 13.24 IREV-i/R 51 �� � 0� —�� <br /> EH 11.26 <br />