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4 APPLICATION FOR PERMIT <br /> *- + SAN`JOAQUIN COUNTY -PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ' <br /> PHONE (209)468-3420 <br /> 445 N SAN JOAQUIN, t <br /> P O BOX 2009, STOCgTON, .CA 95201 <br /> t PERMIT EXPIRES YF FROM D TE I <br /> SSU <br /> (Complete in Triplicate) <br /> ork feeds to San Joaquin county for <br /> tY ordinanceto go. 5k9 18�struct and/or s d thetall Rules <br /> endeReBulationin sdof This <br /> Application is hereby lr4 V /171 <br /> application is made in coa�liance with San r t[[ /t r !✓ <br /> dosquin County Public Health Services. d Lot Size/Acreage <br /> City <br /> dress <br /> Job Ad ! <br /> . -a �- � �'" "� :�, t�� Phone <br /> Address <br /> Owner s Name phone <br /> icense No, <br /> ass DESTRUCTION ❑ put of Service Well ❑ <br /> Contractor WELL REPLACEMENT C7 Monitorina Well C3TYPE OF WELL PUM NEW WELL ❑.` OTHER ❑ <br /> • SYSt-EM REPAIR ❑ LINE <br /> SEWER LINES � <br /> PUMP INSTALLATION 0 DISPOSAL FLO. <br /> PROP�� _.�._ <br /> DISTANCE TO NEAREST: SEPTIC TANK : �� t OTHER WELL <br /> P17SISUMPS <br /> FOUNDATION —Y— AGRICULTURE WELL ��-- <br /> PR09LEM AREAP CONSTRUCTtONSPECIFICATIONS <br /> INTENDED USE TYPE OF WELL Dia of Well Casing <br /> ❑ Manteca Dia. of Well Excavation <br /> 1 C7 Industrial ❑ Open Bottom Specifications <br /> 0 Tracy r TYpe,of Casing_. <br /> [-I Domestic/Private Cl Gravel Pack Type of Grout <br /> ! I'1 Public l I Other <br /> {11 pelta t Depth of Grout Seat <br /> 1 L Surface Saa1 installed by <br /> I 1 Inigatian �-APProx. Depth l 1 Eastern : ; State Work Done <br /> H.P. � " <br /> Repair Work Done L] Type of Pump -�� JSe <br /> ing Material Depth <br /> Well Destruction ❑ Well Diameter �� s <br /> Filler Material i Deft_ <br /> f Depthsews( - .. <br /> * available within 200 feel.) <br /> "�t�TYPE OF SEPTIC WORK:. NEW INSTALLATION A REPAIRIAUDlTION 14 DESTRUCTION ave septic system permitted it pubis i <br /> other <br /> Installation will serve: Residence Commercial07 <br /> $ <br /> Number of living units: -I-- Number of bedrooms D Water tab4o depth <br /> Character of sop to a depth of 3 feet: <br /> ' Capacit No. Compartments <br /> SEPTIC TANK` 1.�� O Type/Mfg Method of Disposal <br /> Pro �- <br /> PKG. TREATMENT PLT ❑ Foundation Q i perty Line <br /> Distance to nearest: ll� r - <br /> Total length/size <br /> I. LEACHING LINE ❑ No. b Length of linea <br /> t '�. `Foundafiont' PropeAy Linsn <br /> FILTER BED 0 Distance to merest: �tYVall�.--- , , � <br /> Number <br /> SEEPAGE QTS I 1 Depth S1TBD <br /> "Well-44-0—Foundation ---P�Pett1'Lirte <br /> LIMPS LI Distance to nearest: <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, an <br /> rules and regulations of the San Joaquin County <br /> Home owner of licensed agent's signature certifies the following: "l certify that in the-performance of the work for which tris permit is issued, I signature <br /> shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of-California." Contractor's hiring e;to orktman1se mponso- <br /> certifies the following: "I certify that in the performance of the work for which this permit issued, l shall employ pe 1 <br /> tion laws of California." �, <br /> The applicant rtxi call for I requi spections. o plate drawing on reverse side. f, j <br /> Title: <br /> {` Date: <br /> Title- <br /> Signed <br /> F 1 <br /> F RTMENT USE ONLY <br /> • Date y c�"T Area <br /> ;*`IGGrout <br /> atkan Accepted byrDateFinal Inspection I Inspectbn by 6 <br /> Additional Comments: <br /> Applicant - Return all copies to: Environmentaloaquin County <br /> HealthPublic <br /> Permit/BerviceeV�ces ' <br /> 445:14 San Joaquin, P ox 2009, Stkn., CA 95201 <br /> CK ECEIVEO BY ATE PERMIT'NO. <br /> LINFO <br /> AMOUNT DUE AM UNT REMITTED' CAS <br /> EN 1344 UIEV,t/e W Q�EH 4 r <br />