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APPLICATION_ FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 <br /> ENVIRONMENTAL HEALTH DIVISION n <br /> 3601 E. HAZELTON AVE. , PHONE (209?468-3420 <br /> gTON. CA 90201 <br /> p O BOX 2009, STOC <br /> r R.F l Y AR FR01d D 1 <br /> (Complete in Triplicate? <br /> t to construct and/or install the work herein described. This <br /> Ia and 1862 and the Rules and Regulations of San <br /> Apyllcation is hereby made.to Sen'Joaquin County for a permit <br /> N 549 <br /> 2iance..vit.1 San Joaquin County <br /> application is made in comp ��� J <br /> Joaquin County Public Health Services. Lot Size/Acreage i <br /> City ' <br /> Job Address Phone <br /> i <br /> } dress <br /> Owner's Name <br /> Phone <br /> icense Nil <br /> Address pESTRUCTION t_ Out of Service Well ❑ <br /> Cont{actor WELL REPLACEMENT Idonitoring Well C]NEW WELL C OTHER 13 TYPE OF WELLIPUMP, SYSTEM REPAIR C PROP, LINE <br /> PUMP INSTALLATION O DISPOSAL SEWER LINES FLO• <br /> -- <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL — <br /> PITS/SUMPS <br /> FOUNOATiON <br /> f TYPE OF WELL PROBLAREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED Manteca Ria. of Well Excavation�— Specifications <br /> C'i industrial O Open Bottom O Type of Casing <br /> C Tracy Type of Grout <br /> ;.l Domestic/private Ci Gravel Pack n Delta Depth of Grout Seal <br /> I I'1 Public <br /> 1-1, Other fSeal Installed by <br /> Arox1 Depth l I Eastern Surface <br /> I lrligation pp <br /> -- State Work Done <br /> J Type of Pump ---------- H.P. --�---------"` <br /> Repair Work Done Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material pth <br /> I <br /> Depth <br /> available within 200 faet.I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I DESTRUCTION I I (No septic system Permitted if pub rc st=ove <br /> I + Commercial Other — --�— <br /> installation will serve: Residence y <br /> Number of living units: Number of bedrooms Water table depth <br /> ` Character of soil to a depth of 3 feet: Capacity----- No. Combartments � .�•_ <br /> r. <br /> { SEPTIC TANK ❑ Type/Mfg r ��,�_,..... Method of Oisposal „ <br /> r PKG. TREATMENT PLT. ❑ Foundation_--— Property Line------'— <br /> Distance to nearest: Well <br /> ` Total length/size <br /> Ll No. & Length of lines Property Line <br /> LEACHING LINE <br /> Well C22 Foundation <br /> FILTER BED CI Distance to nearest: 1 <br /> I Number f—=---- `— <br /> k �10�Plt", Size Property LineSEEPAGE PITSn FoundationPS Ise to nearest: Well 1 12 0--\'v <br /> state laws, arxf� <br /> DISPOSAL PONDS Cl _ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, r <br /> r,�� , - ice of ermit is issued, (shells <br /> rules and regulations of the San Joaquin County 9, „ Penia. w�`_\� <br /> mans subject to workman's compans. <br /> Home owner or licensed agent's signature certifies the followin i certify that m the rforrnance of the work for which is D <br /> employ any Person in such manner as to homer subject <br /> t toworkman's <br /> workan's compensation <br /> om ens sperm Ws iof Calif)shall emp otyapars s hiring or subcontracting signs <br /> certifies the fogowing: "I certify that in the perto <br /> tion laws of California." 1 g Tse side. }° <br /> The applicant must 11 for all r ed inspections. C stip ete drawing on <br /> �,. Date: <br /> Title: <br /> Signed <br /> FOR DEPARTMENT USE ONLY J <br /> DArea <br /> ate <br /> A iceUon Accepted D <br /> Final Inspection <br /> Date b <br /> 1 Pito Grout lrtspectio` -7 521 <br /> dditionai Comments: public Health <br /> Applicant - Return all copies to: San Joaquin County <br /> Services, $nvironmen2009, <br /> tal Health 009Stockton, <br /> to kton, CA 95201 <br /> G 1601 E. Hazelton Ave-, P 0 Box 2 ' PERMIT NO. <br /> I CK RECEIVED By GATE <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> I INFO r ry `�. �j" rl D CIO"/V40 <br /> �. EM 1}2t INEV.t i r e� ,J 4.OL) l.. <br /> EM;t•2e <br />