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APPLICATION FOR PERMIT <br /> SANT jOAQUIN COUNTY PUBLICHEALTH <br /> HDIVISISERVICES <br /> ENVIRON![ENTTAL HEALTH <br /> ON <br /> 445 N SAN iOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> � T ggpIRES <br /> FROM DTE <br /> (Complete 11 in Triplicate) <br /> for a permit to construct and/or install the vont herein described. This <br /> Application is hereby mcompliade.to San <br /> Joaquin County Regulations of San <br /> application is mere is compliance with San County <br /> County or <br /> No: 549 and 1862 and the Rules and <br /> Joaquin County Public Health services. <br /> Lot Size/Acreage <br /> Job Address c� 1 0 � <br /> f, <br /> � Address <br /> Owner's Name `pho�2Z^ 2 <br /> If Qt c } License Ilo. <br /> Ift ( Address DESTRUCTION ❑ Out of Service well <br /> Contractor WELL REPLACEMENT ❑ ldonitoring well ❑ <br /> N W WEL OTHER ❑ <br /> j TYPE OF WELtlPUMP: SYSTE REPAIR ❑ PROP. LINE <br /> PUMP INSTALl1{T N ❑ SEWER LINES �- DISPOSAL FLD. <br />` � .` - _ ,,THER W.EL PITS/.SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK ""__ � �� AGRICULT.URE_WELVI -�' r <br /> FOUN DAT10N_r�d��,= p� <br /> TYPE OF WELL PROBL�REA CONS7RUGTkON SPECIFICATIONS Dia. of Wel! Casing <br /> INTENDED USE ❑ Manteca Dia. of Well Excavation <br /> ❑ Open Bottom pecifications <br /> Cl Industrial Type of Casing_ <br /> oval Paek ❑ Tracy � r' Ty o rout <br /> Domestic/Private CBS 1 ❑ pairs Depth of Grout Seal <br /> I'1 Public' f1 other <br /> splh I I Eastern Surface Seal Installed by <br /> I 11 Irrigation H.P. <br /> State Work Done <br /> Repair Work Done Ll Type of Purflp �-- Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter �--r Piller Material 4 Depth <br /> Depth f I iNo sepHcaystem permitted if pubic <br /> available within 200 test.) t <br /> TYPE OF�EPTIC WORK: NEW INSTALLATION I 1 REPAIRJADDITION i I DESTRUCTION sewer r <br /> T <br /> j Installation will serve: <br /> Residence Commercial Other�-- <br /> Number of living units: <br /> Number of bedrooms Water table depth <br /> Character of SON to a depth of 3 fest. Capacity--� No. Compartments <br /> SEPTIC TANK 0 Type/Mfg "tFw `6 <br /> PKG. TREATMENT PLT.❑ i Foundation �-- Props \ <br /> Distance to nearest: Well 1 <br /> Total length/s � Y <br /> LEACHING LINE C1 No. b Length of lines Prf � s <br /> ❑ Distance to nearest: Wali Foundation --- pk TTH SER CSS <br /> FILTER BED 1 5 <br /> I I Depth-tSize <br /> Num6�111 NMENTAL <br /> i SEEPAGE PITS r Foundation -- Property Line�.--- <br /> i SUMPS Ll Distance to nearest: Well .41 - <br /> DISPOSAL PONDS ❑ '-=--" r= --_., <br /> ' urti 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 hereby fy <br /> rules and regulations of the San Joaquin County following: ,I certify that in the performance of the work tot <br /> Home owner or licensed+gant't as to ebecome subjecoertifies the to workman s compensation laws of Califorrnia." Contractor's 1h ri g or ch this subfmi contracting cornPen is issued, I shall �- <br /> employ any person in such man persons subject to workman's compensa <br /> certifies the following: 11 certify that m the performance_of the work for which this permit is issued, I shall smploy pe � <br /> tion laws of California." <br /> The applicant at call for all required inspections. Complete drawing o revers} ida. <br /> Title: Date: <br /> signed `' <br /> R p RTMW USE ONLY ��� <br /> DateAr <br /> Application Accepted by pate <br /> Date�--- Final Inspection by <br /> Pit or rou Inspactbn by ,�—�7 � • <br /> Additional Comments: y <br /> Applicant— all copies to* Environmental UAtY HealthuPermiblic t ealth vices <br /> /Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 k <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> K RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> • EN 13.24 tHEV.V n 6) 5!/ O <br /> EN 11.36 <br />