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At4�i�ioo�Ir�1r <br /> APPLICATION FOR PERMIT C14-4•-U Sd <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESc <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 93 _ D9 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERM T E%PIRE 1 YE FROM D TE <br /> �I (Complete in Triplicate) <br /> Application is hereby Ama+de-to Ban ,Joahu1in o�uinocounr a ty ordinance rmit to nNo. 549struct aand o1862sand the tall eRules and vorx eRegulationin s Of Sand. s <br /> application in mad <br /> Josquin County Public Health Services. Lot Size/Acreage <br /> 3�f -DWe,t City <br /> Job Address <br /> Phone, <br /> Address _ x.- �CSy <br /> Owner's Name - -„- .�- ��.t -�-_"'- `".."�' <br /> 4 __ License No �7 Phone <br /> Address put of Service Well ❑ <br /> Contractor WELL REPLACEMENT C] DESTRUCTION ❑ <br /> . NEVY..WEt L CIS- OTHER ❑ n'itforin8 Well p <br /> TYPE OF WELL/PUMP: r SYSTEM REPAIR ❑ 1 <br /> iPUMP INSTALLATION ❑ PROP. LINE: <br /> '� SEYy.ER-LINES DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK �— OTHER WELL.--� PITS/SUMPS <br />'r " AGRICULTURE WELL <br /> I. FOUNDATION TYPE WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE -- Dia. of Well Casing <br /> Cl Industrial ❑ Open-Bottom ❑ Manteca Dia. of'WeH Excavation Specifications 1 <br /> kI ' ❑ Tracy -.Type of Casing <br /> C] Domestic/Private ❑ Gravel Pack ` DePth ot;:Grout Seal Type of Grout <br /> I'l Public 1:1 Other ' f'1 Deity,p <br /> Approrr:Depth l 1 Eastern T �, Surface Seal installed::by, I <br /> I I Irrigation 'k I State Work Done <br /> Type of Pump �� H'P' i <br /> Repair Work Done U Sealing Material Depth � <br /> Well Destruction ❑ Welt Diameter <br /> Depth llller Materialf i Depth <br /> I n_ 1 ._..w_ -.� . .- r <br /> TYPE OF SEPTIC WORK:a NEW INSTALLATION I 1 REPAY 0ffi% ITION I�DESTRUCTION I available�wi hin 200 feet'led if public sewer is <br /> Installation will serve: Residence V Commercial <br /> Other <br /> Number of living units: =-fir— Number of rooms Wat bb depth f <br /> Character of aoit to•depth of 3 feet: `p �r No. g�npertments �- <br /> T lM1g Capacity <br /> SEPTIC TANK. LY Type/Mfg tr Method of Disposal <br /> PKG. TREATMENT PLT.0 1 1 �i property Line <br /> Distance to nearest: Wel! 4� Foundation F S <br /> Total lengthtsize <br /> i LEACHING LINE', ,eT�No. i Length of lines f <br /> i f Foundation -- Property Line <br /> FILTER BED [:IneN <br /> Distance to rst: Well I • <br /> tf Number <br /> + SEEPAGE PITS III Depth Site <br /> SUMPS IDistanea'to nearest: Wei <br /> n <br /> f Foundatio -�- Property L+ne�L-1� -- <br /> DISPOSAL PONDS ❑ <br /> that the work will be done in accordance with San Joaquin county ordinances, stats taws, and <br /> I hereby certify that I have prepared this application and <br /> rubs and regulations of the San Joaquin county <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 signature <br /> shall not <br /> employ any person in suchmanner that a to n fb p�sr�forsubject to mwnce of he workaforawfi ththis tperm on vis issued, I shall employ of California." tapeosonsrsubjectring rto worktmon'scompenss- <br /> + certifies the follawing:' <br /> tion bwa of California.•• } r <br /> s. Complete drawing on reverse side. <br /> ' <br /> The applican ust It for all required spect' <br /> t 4 3 Date: <br /> Signed Tide: <br /> ` i <br /> 4t FOR DEPARTMENT U ONLY <br /> ;Date Area, j <br /> Application Accepted by. <br /> Pit or Grout Inspection by Date, _ <br /> Final Inspection by t Date <br /> Additional Comments: !OC-Q J 30� �eaW <br /> l <br /> Applicant - Return all cppies to: San 3oaquin County Public Health Service <br /> Ar Lrli�f <br /> I r 95 <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 01 <br /> CK RECEIVED BY DAT PERMIT'N0. <br /> FEE MOUNT DUE AMOUNT REMITTED CASH <br /> INFO � Q <br /> . EH 13.24 IAEV.tiir+t;+ <br /> EN 14.21 <br />