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APPLICATION FOR' PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNetENTAL HEALTH DIVISION <br /> jP O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y <br /> (Complete in Triplicate) ; <br /> Joaquin County for a permit to construct and/or install the work herein described. This <br /> Application 1e hereby taade,to San I <br /> application is made in.00mpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Address 1 .01 Lvd; <br /> n City �--�- Lot Sitse/Acreage <br /> _ tI <br /> J iI -Address D4 �" Phone <br /> Owner's Name C`l/ S` j <br /> I �A �txirrl� x� License No.— <br /> Contractor �� �r�L¢ Address <br /> NJECI R£PLAGEMENT M_ DESTRUCut of <br /> NENy�VVEI'L'❑ �' TION Cl OService cell ED <br /> TYPE OF WELL/PUMP: OTHER ❑ M10onitoring . <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES -- DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it <br /> Dia. of Well Casing <br /> C� Industrial ❑ Open Bottom fa Manteca Dia. of Well Excavation_ Specifications <br /> U Domestic/Private El Gravel Pack 0 Tracy Type of Casingof Grout Seal Type of Grout <br /> G Public ill Other 1 ❑ Defta Depth <br /> Ct Irrigation AptNox• Depth 0 Eastern Surface Seal Installed by r <br /> H:P. �^ State Work Done _ <br /> Repair Work Done U Type of Pump �---- Sealing Material i Depth <br /> Wall Destruction ❑ Well Diameter <br /> i '� Fiiler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REP.AIAIAD.D,ITkON L7 DESTRUCTION F evailebPill <br /> ewithin 200 fe8itied if public sewn is C <br /> . ' \ [ <br /> 4 Installation will serve: Residence_-I_- Commercial <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet l I <br /> SEPTIC TANK k' Type/Mill fw'~ <br /> 6Ai r•`►�iii ' r Cspacity'' atrZ - Ni Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT,G7 :yj; °° f r } . (p " <br /> Distance to nearest: W <br /> t7 r Foundation CU Property Line <br /> e��=�---�-} <br /> No. 6 Len ih pi"tines--lam' Total length/size <br /> LEACHING LINE ,g p � property Line � 1 <br /> FILTER BED n Distance to nearest: Watt 112e) Foundation�� <br /> k �� i E" " Number <br /> SEEPAGE PITS 'T Depth ' Size <br /> Property Line <br /> SUMPS <br /> E;1 Distance to nearest: Well foundation 401 e - <br /> DISPOSAL PONDS ❑ 41 1 1 � <br /> I hereby certify that I have prepared this.application and that the work will-e done in accordance with San Joaquin county ordinances, state taws, an <br /> j rules and regulations of the San Joaquin-County i <br /> Home owner or licensed:peat's signature certifies the following: "I certify that in the performance of the work for which this permit,is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation-laws of-California." Cnntractar's hiring or sub contracting signature <br /> cartifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to work m en's compansa• <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on rave. side: ` !f 47 <br /> Title: !�'" 'll <br /> Signed <br /> FOR DEPARTMENT,USE ONLY -2- <br /> � <br /> Data Area <br /> A plication Accepted by l U <br /> ate <br /> - � Dv <br /> PI r Grout Inspection by Date's Z Final Inspection by <br /> Additional Comments; <br /> 't <br /> Applicant - Return all copies to: SAM JOAQUIN COUNTY PUBLIC -HEALTH SERVICES \( <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> It <br /> 445 N SAN JOAQUIN, P 0 BOX"2009, STOCKTON, CA 95201 /L\' <br /> FEE AMOUNT pUE AMOUNT REMITTED CASH RECEIVED BY / DATE PERMIT'NO. <br /> INFO 1 f(�, <br /> . I 13.71(REV.1ias] <br />