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-- APPLICATION FOR PERMIT A <br /> Ali- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> l 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 1 ' <br /> PER1[IT EXPIRES 1 YEAR FROM DATE ISgUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is mads in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> XJob AddressZ�� ������ � City Sr4a 611q&>n_ Lot Size/Acreage !•7S'.,t �d <br /> XOwnsr's Name 2� Address Phone Ty x- z <br /> n Contraclof Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ \1E <br /> REPLACEM T ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> r PUMP INSTALLATION ❑ SYSTEM PAIR O OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWEDISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICEWE OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CINXTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom © Manteca D. of Well Excavation Dia. of Well Casing <br /> [7 Domestic/Private ❑ Gravel Pack ❑ Tracy yp of Casing Specifications <br /> I'1 Public 1-1 Other n Delta Dept of Giout Seal Type of Grout <br /> I Irrigation �..Approx. Depth i I Eastern Surfac Seal Installed by <br /> Repair Work Done 0 Type of Pump H. State Work Done <br /> Well Destruction D Well Diameter eating Materi & Depth <br /> Depth Filler Material Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted it public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence_2!� Commercial__._ Oiher <br /> Number of living units: Number of bedrooms _ <br /> s Character of soil to a de�pthh !�3 feet: QU�� Water table depth u-30 <br /> SEPTIC TANK. L9" Type/Mfg _ d..__ Capacity Aa0 No. Compartments <br /> PKG. TREATMENT PLT. D , CP ' Method of DisppSal <br /> Distance to nearest: Well �� ' Foundation t O Property Line z I <br /> LEACHING LINE P"—No. & Total length/size of lines Length O <br /> g � <br /> (_ FILTER BED CI Distance to nearest: Weil�W '' Foundation Z-0 Property line S_i <br /> —] <br /> SEEPAGE PITS I,_I' Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be d6ne in accordance with San Joaquin county ordinances, state laws, and <br /> 1 \ rules and regulations of the San Joaquin County `- <br /> Home owner or licensed agent's signature certifies the following;-"I certify that in the-peri6rmance 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 taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- _ <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title. /Z/ Date: 3 I'C'J <br /> r <br /> EPARTMENT USE ONLY <br /> Application Accepted by Date �� Ar <br /> Pit or grout Inspection by Date f Final Inspection by• Date (1 C v <br /> Additional Comments: Lo �,A 5a f Gr``Ii <br /> Applicant - Return all copies to: San Joaquin County Publi health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IFEE `OUNT DUE `AAMM/OUNT R <br /> EEMITTED CK <br /> CASH RECEIVED 6Y DATE PERMIT N/O'. <br /> + EH t3.241AEV.r/A51 <br /> EH 4{20 © o.0-a / arV A cf f <br /> Q S C� <br />