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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y R <br /> (Complete in Triplicate) <br /> tall <br /> work <br /> in <br /> Application is made <br /> binmade,to S90 <br /> ca*11ance vithuin SancountyJoaquinor a county Ordinancermit to nstruct No. 549aando1862sand theeRules andeRegulationsdof Bans <br /> application is mads o� . <br /> Joaquin County Public Health services, <br /> 43 6, (,'�1/ASIVA) C� City S7�CAJ Lot Size/Acreage <br /> Job Address <br /> Owner's Name <br /> Address <br /> 371ps L OX 2D ;53� Phone <br /> LTJ D E, l 0626 - Address A 4D'Er`BE.eT —License No. 7L_Phone <br /> Contractor DESTRUCTION ❑ Out of Service Well ❑ <br /> WELL REPLACEMEN ,n Monitoring Well Irl <br /> TYPE OF WELLIPUMF: NEW WELL ❑ SYSTEM RE IR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> S ER LINES DISPOSAL FLD, PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK pTHER WELL lumps <br /> RUCTION <br /> FOUNDATION �.� AG CULTURE L <br /> AR A <br /> NST SPECIFICATIONS t <br /> TYPE Of WELL PROBLEM _ ia. of Well Casing <br /> INTENDED USE D <br />` f_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> k ❑ Tracy Type of Casing <br /> U Domestic/Private ❑ Gravel Pack epth of Grout Seal Type of Grout <br /> 1-1 Other ❑ Delta <br /> �3 Public dace Soul installed by <br /> CJ irruation .Approx. Depth ❑ Ea rn <br /> H P State Work Done _ <br /> Repair Work Done U Type of Pump Sealing Material fe Depth <br /> Well Destruction D Well Diameter Filler Material 4 Depth <br /> I Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIRIADDITiON II DESTRUCTION CI lNo availseI within 200 feet-1 if p7sawerinstallation will serve: Residence 11 <br /> Other Pa,4L-I G td <br /> Number of living units: -/— Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: ..`-�X j�pp Na. Compartment <br /> Capacity - <br /> s <br /> SEPTIC TANK f KTYM/Mfg <br /> Method of Dispose{ <br /> PKG. TREATMENT PLT. 0 qQ foundation �Z �- Property Line Id <br /> Distance to nearest: Well ____y""""_ (� <br /> Total length/size- <br /> aCl <br /> LEACHING LINE No. fit Length of lines " e , O <br /> N Foundation - Property Liner <br /> FILTER BED LI Distance to nearest: Well <br /> SEEPAGE PITS I Depth 5—' Silo Number <br /> SUMPS LI Distance to nearest: Well �y„L6.� Foundation--LV-9L— Property Line <br /> DISPOSAL PONDS ❑ <br /> i <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 awe, and <br /> rules and regulations of the San Joaquin county <br /> j Home owner or licensed agent's signature certifies the foilowing: "I certify that in the performance of the work for which this permit is issued, i shall not n <br /> i employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature <br /> eanifies the following: "I certify that in the performance of the work for which this permit is issued. I shell employ persons subject to workman's Compenaa• <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side'. - <br /> Signed Title: <br /> o�?ifi�t- fJa:e: <br /> .—FOR-DEPARTMENT-USE-ONLY---- <br /> 1 ' Date ---- Area. <br /> Application AcceptedData <br /> b fU Zb <br /> Pit or Grout Inspection y Data -- final inspecti <br /> y <br /> on by <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES T TT <br /> ENVIRON <br /> -"— MENTAL_HEALTH_DIVISION._PERMIT/SERVICES:' <br /> 445 N SAN JOAQUIN, P O BOX 2009- STOCKTON, CA 95201 <br /> � OK RECEIVED BY DATE PERMIT N0. <br /> FEE AMOUNT DUE AMOUNT REWTTED <br /> INFO <br /> 96r <br /> . EN 13.21 IREV.1 e 51 t` �� \ OD <br />