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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Q ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 p O BOX 2009, STOCKTON, CA 95201 <br /> 1 \� PFAU*T EI PIRES 1 YEAR FROId DATE ISSU__Et� <br /> � t (Complete in Triplicate) <br /> Appiicetion is hereby sada to San Joaquin County for a percit to construct and/or install the work herein aescribed. This <br /> application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the }tines and Regulations o` San <br /> Joaquin County Public Health Services. v <br /> ,� _ City Lot size/Acreage <br /> Job Address _ ` 1i� 1, 7rF` ,2 <br /> r <br /> IA�t2 Phone <br /> i/,L� Address ___S- <br /> Owner's Name / g5Q jv <br /> ::Cense ti ..S -Phone c7�`!a <br /> Cor.IIactof Out of Seryicc Well 0 <br /> NEW-4V£ti := - �WELi REPLAGfMENT ,:, DE 7AU..TtON .... <br /> TYPE OF WELL:PUMP. OTHER Z Monitoring Well <br /> PUMP INSTALLATION Z SYSTEM REPAIR �. <br /> — DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ PITS/SUMPS _ <br /> FOUNDATION AGRICULTURE WELL OxHER W-ELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO SPECIFICATIONS— <br /> Dia of Well Casing <br /> ndustnal C: Open Bonom �. Manteca pie. of Well Excavation_______------ <br /> Type of Casing.- Specifications <br /> Domestic/Pnvate i_'. Grave: Pack Tracy Type of Grout <br /> Public Other Delta Depth of Grout Seal _------ <br /> irnpdtion __ Approx. Depth I Eastern Surface Seat Installed by <br /> P State Work Done _ <br /> Repair Work Done r, Type of Pump H Sea.ling Material Depth <br /> Weil Destruction J Well Diameter 111+er Material i Depth <br /> Depth . <br /> DESTRUCTION <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I REPAIR/ADDITION I availablewithin200ftrad d public sewer is <br /> feet <br /> e <br /> Insiaiiation will serve: RdaNumber of bedrooms nce ✓ Commercial___.n <br /> 4- r <br /> Number of Irving units: LU Water table depth <br /> Character of soil to a depth of 3 feet'. No. Compartments <br /> SEPTIC TANK C31 Type/M19 '1� Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. 0, _ <br /> Property Line <br /> Distance to nearest: Foundation <br /> st: `dP <br /> _ { <br /> LEACHING LINE L No. 8 Length o1 lines Total length size_ <br /> property Line �- <br /> FILTER BED 11�Oistance ig nearest: <br /> Foundation tZsr�- <br /> Depth _ Sixe Number <br /> -- <br /> SEEPAGE PITS property Line <br /> SUMPS Distance to nearest: Weil Foundation <br /> DISPOSAL PONDS ;_; <br /> I nereby ceri,ty that I have prepared this eppftcatton and that the work w:d be done in accordance with San Joaquin county ordinances, state taws, an <br /> rules and regulations of the San Joaquin County permit is Issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "i certtty the: in the performance to the work for which ng pa signature <br /> employ any Derson in such manner as to become subject to workmen's compensation laws of Cantornla."Contractor'shiringocrts0 WOfktrTa�1!aC rrtpensa <br /> certifies the following: "I certify that in the parformance of the work for wh;Ch this permit iso sued, 1 shah employ Pa <br /> tion laws of California." <br /> The applicant-must eau for aft required spa tions. Complete drawing on reverse side. <br /> Date: <br /> Signed X <br /> n 0 Fj PARTMENT USE ONLY <br /> \/ Aa+1G-� Date -�-`— r <br /> Application Accepted by _-�► �u �- <br /> Date <br /> Pit or Grout Inspection by Date Fina Inspection by <br /> P <br /> Addatonal Comments: <br /> Applicant - Return all copies to: Sen ices, Environmental Public ServHealth <br /> 1601 E. R&zelton Ave., P 0 Box 2009. StOciLtOr. CA 95-001 <br /> CK RECE VED BY <br /> FEE DATE PERMlT NO. <br /> AMOUNT OuE AMOUNT REMITTED CA! <br /> INFO <br /> E+,324 iPty o <br /> E� .� <br /> 20 <br />