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�: ° ;; •ii APPLICATION FOR PRaM I T <br />SAN JOAQUIN COUNTY. PUBLIC HEALTH SERVICES <br />ENVIRONUBN'TAL .HEALTH DIVISION <br />7�G0 9. HAZELTON AVE., PHONE (209)468-3420 <br />P Q BOX 2009, STOC%TON,. CA 95201 <br />- <br />(Complete is Triplicate) <br />MOUNTR IT -TE -13 <br />� <br />+ � <br />>h H ,f <br />Applicdtion is hereby. toade to San Joe <br />Luin County for a permitto construct and/or install the vork herein described. This <br />application is txpde in ecW11amoe vit <br />k Sen Joaquin County Ordinance No. Ski e,od 1862 and the Rules and Reguletlooe of Sen <br />Joaquin County Public Health Service <br />r <br />SI&A_._Lot size/Acreage <br />City <br />Job Address <br />` <br />A� <br />n/ ^i <br />�'- "` r�E Phone �4 ^ ~ 56 <br />QWnal Nemo C �' ( <br />Addre�a <br />17G License No 377 Phone <br />Corittaclor laZ)`4 <br />Address <br />TYPE OF WELL/PUMP. NEW <br />ELL O WELL REPLACEMENT DESTRUCTI t.of service Well <br />PUMP INSTALLA <br />ION IW SYSTEM REPAIR ❑ OTHER O 149vatoling Well ❑ <br />DISTANCE TO NEAREST; SEPTIC TANK <br />SEWER LINES DISPOSAL FLO.!L- PROP. LINE <br />FOUNDATION <br />AGRICULTURE WELL OTH[R WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL <br />PROBLEM AREA CONSTRUCTIO14`SPECIRCATIONS e <br />G1 Industrial , 0 Open Bottom <br />Q Manteca Ola, of Well Excavat 01" Well Casing � <br />_i4woomeSNc/Private 'W Gravel Pack <br />❑ Tracy Type of Casing .. __ Spilblications--=�:ZL <br />/ Type Groutsr^�c�`1 <br />I'I Public r Other <br />Cl Oat( a OaP1h of ;Grout Seal of <br />I I Irrigation -X'V %) Approx. Da <br />11 Eahtarn 'SLAAce Seal Installed by . t3x rXA4l/R <br />L.: <br />Repair Work DOM U _Type of Pump <br />H. P. � � - S'tale Work Done ._ rilftf t✓�a <br />wall Destruction V Well Diameter <br />sealing Materiel E Depth <br />�'�. <br />Depth <br />Filler Material i Deypt <br />TYPE OF SEPTIC WORK: NEW INSTALLA <br />ION I I REPAIR/ADDITION I I_ DESTRUCTION I I (No sapfic system permitted it public server uir <br />available within 200 feet. <br />Installation will urve: Residence r C <br />mmercial _ Other <br />Number of living units: Number o <br />bedrooms ` <br />Character of soil to a depth of 3 feet: <br />Water table depth <br />SEPTIC TANK. ❑ Type/Mfg <br />Capacity `No• Compartments <br />PKO.'TREATMENT PLT, O <br />Method of Disposal <br />Distance to nor <br />t: Well Foundation Property Line <br />H <br />LEACHING LINE O No. 6 Length <br />f lines Notal length/sire <br />FILTER BED .O Distance to no <br />rest: Welt' Foundation Property Lina <br />SEEPAGE PITS 11 Depth <br />Size Number <br />SUMPS CI bistance to <br />Well FourtQai;on Property Lime <br />DISPOSAL PONOS ❑ <br />s <br />I hereby certify that I have prepared this <br />lion and that the work will be done in accordance. with San Joaquin county �rdinanees, state laves, and <br />rules and regulations of the Sen Joaquiny <br />Home owner or licensed agent's signatures <br />the following: "I certify that in the performance of the workAor which this permit is,,issued. 1 shelf tot <br />employ any person in'such rrannaraz-t6 <br />%&ject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature <br />cendies the following: "I certify that in the pill <br />ofmance`of the work for which this permit ie issued, I shall employ persona subject to workman's compensa- <br />tion Iswa of Cslifoinie " <br />The applicant must call for all r6q red insps <br />ions. Complete. drawing on. reverse side. <br />�%ri"- Date:�� <br />Signed <br />Title: .,�. <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by <br />Dafe" Areae <br />Pit or out nspection by <br />Date nal Insde Dat <br />Addhbnal Comments: <br />Applicant - Return all copies to <br />rJ� � county Health <br />� <br />,,eelbllc <br />�ri'ces;'. i�nvira>i�6ia1 Health Perwlt/Bervicee;? <br />1 <br />E. Hszeitoo Ave.. P 2009. Stockton, CA 95201 <br />. EM t�•7A t11fV. � � � ori <br />-•, eH wa <br />Pte' <br />INFO <br />wM011 E (., <br />MOUNTR IT -TE -13 <br />� <br />+ � <br />>h H ,f <br />P_�� �Y DA7F P RMIT <br />., <br />;o y <br />