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APPLICATION FOR PERMIT <br /> SAN .70AQUIN COUNTY PUBLIC HEALTH SERVICERECEIVE U <br /> ENVIRONMENTAL HEALTH DIVISION r <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 L 2 7 1990 <br /> P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> PERKIT EXPIRES 1 YEAR F ON AA`s PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> Application is hereby mde,toSan Joaquin CJoaquia Counr a ty Ordioancermit to nNo. 549 ando1862 and thethe <br /> Rules work h" Regulationerein sdof San. This <br /> application is made in camp � San <br /> Joaquin County Public Health Services. <br /> Size/Acreage <br /> Job Address <br /> 1 U r ddress Phone qt <br /> Owner's Nam��J <br /> ((,actor <br /> �� We, � / I cense No �U/ Phone d <br /> NEW WELL ❑ WELL REPLACfME T ❑ DESTRUCTION D put of Bervlce Xell L1 <br /> TYPE OF WELL/PUMP. OTHER Cl Monitoring Well D <br /> PUMP INSTALLATIOIl SYSTEM REPAIR Cl <br /> SEWER LINES DISPOSAL FLD. PROP. LINE d <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> _ FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dial. of Well Casing �n <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavatiOA~ Specifications ry' <br /> `>_14omesticlPrivate E3 Gravel Pack D Tracy Type of Caring <br /> I I.1 Public C1 Other Depth of Grout Sea1i' <br /> Type of Grout <br /> fl Delta <br /> I I Irrigation '_.Approx.'Dep h I Eastern ,S dace 5ent-tnstalled by <br /> H.P. ` at on <br /> Repair Work Done U Type of Pump �I healing )Material,&/Depth <br /> Well Destruction ❑ Well Diame e /! O <br /> Depth Filler Material &'Depth <br /> system <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I i DESTRUCTION I I (No sapavailablIw Thin 200 fee permitied it puWie sewer is <br /> t r <br /> { Installation will serve: Resider '_f/Commercial Other,"• � <br /> Number of living units: Number of bedrooms ' <br /> .Water table depth <br /> --- - -- __.. Q <br /> Character of soil to a depth-of 3 feet:- <br /> Capacity i No. Compartments <br /> SEPTIC TANK i 0 ! Type/Mig Method of Disposal <br /> �,. <br /> PKG.TREATMENT PLT:-❑ <br /> Distance to nearest: Well Foundation ,ti Property Line <br /> LEACHING LINE ❑ • No, &'Legh of tines Total lengt�/ ize <br /> FILTER BED rCI Distancal►o nearest: Well foundation Prone <br /> ` SEEPAGE PITS 11 i Depth. Size _ Number' <br /> r SUMPS LIF Distance to nearest: Welt "fbJtidatioh' Property Line ( , <br /> DISPOSAL PONOS ❑ , tV <br /> F 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 /> i rules and regulations of the San Joaquin County: <br /> Homeowner or licensed agent's signature certifies-the following: "I certify that in the performance of the work for which this permit is issued, I shall not T <br /> employ any person in such manner as to become subject to workman's compensation laws of California.'"Contractor's hiring ar sub contracting signature (� <br /> l? ' certifies the following:"I certify that in:he performance_of.the_work_for which this permit is issued l shal I employ persons subject to workman's compensa C <br /> S.?",tion laws of California." <br /> i I v, <br /> The appGca t call or r uirad irtspeetions. Complete drawing on rev side., <br /> I4' Title Date: <br /> i4 Sig d <br /> �c FO DEPARTMENT USE ONLY t <br /> t j Date• �~ Area <br /> Application Accepted by <br /> 14 iDate Final Inapectian by �' Date <br /> I Pit or Grout Inspection by <br /> 4 Additional Comments: <br /> 1, Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E, Hazelton Ave., p 0 Box 2009, Stockton, CA 95201 <br /> i <br /> FEE CK t RECEIVED BY DATE PERMIT NO, <br /> INFO AMOUNT DUE AMOUNT REhtITTEO CASH <br /> EH 13-24 ME,( IiK51 / L �rrd^9fJ <br /> EH 14 2e <br />