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APPLICATION FOR PERMIT <br /> .. SAN JOAENV ENVIRONMENTAL HEDIVISION <br /> V SONLALTH IC HEALTH VICES <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> XP RES ]. VEAR FR DA ED <br /> (Complete in Triplicate) escribe1 <br /> { <br /> in d <br /> Application is h�ebynmade tlolaSan nce Joaquin <br /> thuBanCJoatquinocounr EL ty Ordinance rmit to nNo. 549 and struct o18628and the tall eRules and work eRegulations dof Sans <br /> application <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage y <br /> Job Address <br /> /> <br /> T`y S Phone <br /> Address <br /> Owner's Name <br /> ? d { License No. Phone <br /> Address <br /> Contractor DESTRUC710N L Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Monitoring Well C1 <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR C4 OTHER ❑ <br /> SEWER_LINES—��--�—,DISPQSAL FLP, PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK,•���- PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL��--- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> C7 Industrial 0 Open Bottom ©Manteca Dia. of Well Excavation <br /> Specifications <br /> Type of Casing f ���J <br /> n Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> i"1 Public 11 Other n Delta f <br /> tern Surface Seal installed by <br /> I I Irrigation Approx. Depth I I Eas <br /> of Purrip���— H P State Work-Done <br /> l Repair Work Done U Type Sealing Material & Depth <br /> Well Destruction © Well Diameter Piller Material & Depth <br /> Depth <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ( DESTRUCTION I I aviailablerc system w thin 200 feetr,led rl public sewer is <br /> t t <br /> Installation will server Residence Commercial Other <br /> t x <br /> Number of living units: J_ Number of bedrooms' � i C <br /> Water table depth <br /> Character of soil to a depth of 3 feet: •, No. Compartments <br /> SEPTIC TANK- ❑ Type/Mfg s Capacity ;.. <br /> i _ Method•o1 Disposal <br /> PKG. TREATMENT PLT. ❑ F� - F - I / ' • <br /> Distance to nearest' Well".5a — Foundation, PropeRy Line. <br /> LEACHING LINE lJ$ No. & Length of lines" Total length/size / <br /> ���Foundation �Property,Line <br /> FILTER BED C! Distance to nearest: Well _ - :- <br /> SEEPAGE PITS 11 Depth �� Site Number <br /> SUMPS Distance to nearest: Well 14"1Foundation Property Line z - <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 county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County t <br /> Home owner o►tions of agent's signature certifies the fol <br /> lowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> em>ioy any person.in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the world for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all equire inspecti Complete drawing on reverse side.—. <br /> � ^ Title: .— .��� _ Date: _ �/��� <br /> Signed X {°, <br /> ! -FOR DEPARTMENT USE ONLY -- ` <br /> � <br /> • , � � 7AptAmP7— <br /> Date <br /> Application Accepted by <br /> --.• w _ <br /> a <br /> tion by ate <br /> .�. Pit or Grout Inspection-by Data Final inspec <br /> l Additional Comments: <br /> Applicant - Return,till copies to: ' Stat Joaquin County Public Health .` <br /> pp t3ervices >myixonmental Health,Nrmit/Services <br /> 16}ll E.,;HerielSGptt Ave., p 0 Box 2009, Stockton, CA 95201 <br /> CK rRECEIVED BY , . {SATE PERMIT'NO, <br /> FEE <br /> INFO AMOUNT DUE AMOUNT -EO CASH, f <br /> EH132iIREV.rin5l �/� !,`r- r.�'M '.a. j� „- " 'r' '^"""" �, y it°�«•- 10 <br /> EH 9446 ! U tl (i (7� <br />