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i <br /> APPLICATION ICOR PERMIT <br /> SAN iOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I <br /> O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> (Complete is Triplicate) <br /> vork <br /> made.to Son J!quin County for pe prd3noncenNo. 5k9aando1862sand the tall eRules ondeRegulations in dof Ban <br /> a <br /> Application is hereby liance vith San Joaquin G Y <br /> application is made in cotes <br /> Joaquin County Public Health Services. Lot Size/Acreage <br /> 3 �4_3 <br /> City <br /> Job Address _ <br /> Phone <br /> Address <br /> Owner's Name G _ y <br /> � ,. �Ly�y7 Phone <br /> t •� t1 a D E L.t9�--'T � <br /> License No. ��---- . <br /> F y Gc9dd Address�,- DESTRUCTION Cl Out of Service Wr11 <br /> Contractor WELL REPLACEMENT Cl Well .r r <br /> j NE WEL ❑ OTHER ❑ Monitoring t7 � <br /> TYPE OF WELL/PUMP• SYSTEM REPAIR C1 <br /> PUMP INSTALLATION DISPOSAL FLD,�— PROP. LINE <br /> SEWER LINES PITS/Sl'"PS F <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL_.--- {.- <br /> FOUNDATION AGRICULTURE W <br /> TYPE OF WELL PROBL AREA NSTRUGTION SPECIFICATIONS Dia of Well Casing 1 <br /> INTENDED USE p Manta Dia. of Well Excavation <br /> Ll Industrial Open Bottom Specifications.- <br /> C7 Tracy Type of Casing Type of Grout <br />� U Domestic/Private C1 Grave! pack Q D r t Depth of Grout Seal a <br /> 1 Public 1.1 Other } x, <br /> ApprOx, Depth astern SurlCe.SauClns[aNed by <br /> � IrnOation HIP. State Work Dona — <br /> j Repair Work Done U Type of Pump rim ,,Depth <br /> i Sealing �. ----�-r t�s•� <br /> Well Destruction O Wall Diameter <br /> Depth { Filler Mate al i Depth _ <br /> rmined if public sewer is <br /> available within 200 feat' <br /> TYPE-UP—SEPTIC WORK: NEW INSTALLATION REPAIRlADDITION Ll DESTRUCTION ❑ INo septic system pa <br /> Installation will serve: Residence Commercial — Other <br /> Number of bdrooms e .�yi --� l v <br /> Number of living units: ____L `-:/_'' ' Water labia depth r� <br /> Charscter of soil to a depth of 3 feet: P9L ---— Capacity �!"1L, No. Compartments <br /> ' SEPTIC TANK Type/Mfg L--` �/7- Wthod of Disposal <br /> PKG. TREATMENT PLT. ❑ ! i '' Property Line <br /> 00 Foundation_ -- �11LL-- <br /> Distance to nearest: WeII -- <br /> (�� � Total length/airs � <br /> ' LEACHING LINE No. a Longth of lines �� property Line—,LO- <br /> FILTER BED I1 Distance to nearest: WeII �.,�. <br /> Foundation _ f <br /> ! -Site_ � Number <br /> SEEPAGE PITS -w- _�--I —:Depth ^,zs , Property Linet� <br /> SUMPS LI Distance Foundation—_ <br /> to nearest: We ��-- . <br /> DISPOSAL PONDS ❑ 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stela laws, and <br /> I IL ork for <br /> t not <br /> rule$ and regulations of the San JoaQ6in County g• iha in the <br /> Home owner or licensed agent's signature <br /> certifies <br /> e subject thlto wrorkman'srtcoympenaation lewaoaf Cal fomiah9 Contractovr srhir ng othis f sub"coniract ngermit is issued, l signature <br /> employemploy any person in suchrapes subject to workman's compensa— <br /> tion laws of California." y <br /> The applicant must call for all.requ ed insPections. Complete drawing on revside: <br /> reverse_ Date: <br /> -7— <br /> •r= <br /> Title: L <br /> Signed -� <br /> .µ F DEPARTMENT 115E ONLY I �J <br /> Area <br /> Date G <br /> cation Accepted b <br /> Date - t Final Inspection'b <br /> Data — <br /> C!itloloroui Inspection` _ <br /> Additional Comments: - � � r "~ <br /> SERVICES <br /> TH <br /> Applicant - Return all copiea`tffo:," TALOHEALTH UNTY 0DIVISIONLPERMIT/SERVICES ,v <br /> 1 ENVIRON1[ENN SAN JOAQt1IN, P O SOX 2008, STOCKTON, CA 95201 <br /> GK pECEfVEt) BY HATE PERMI7'NO. <br /> FEE 'AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO' <br /> . EH 13-24(REV-'1 M s) <br /> {H:a.2a <br />