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APPLICATION FOR PERMIT <br /> �7 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 p•O BOXL2009E,VSTOCKTON, CA095201-3 20 <br /> r <br /> EXPIRES 1 E R_FROM DATE ED i <br /> (Complete in Triplicate) <br /> tall <br /> work <br /> in <br /> Application is hereby made, with Sanin County Joaquinor a Covxlty Ordinancermit to nNo. 549struct &and o1862sand the eRuler, and Regulations dof Sans i <br /> application is tirade i compliance <br /> Joaquin County Public Health Services. <br /> I ay <br /> Job Address 4 5 2 0 S , H l h <br /> 9 City�t-O��n_ Lot Size/Acreage 12 . 3 acr j <br /> 10990 Roe Ave. O.P. KS Phone 91 <br /> Owner's Name �/ <br /> Yellow FYel ht 5 stem IT► dress Z� <br /> License No. x— Phone <br /> Contractor Address <br /> NEW WELL ❑ WELL REP AGEMENT ❑ DESTRUCTION L1.Out of Service Weil ❑ <br /> TYPE OF W L/PUMP•. OTH�FB1 CK, Monitoring Well C7 <br /> TION ❑ SYSTEM REPAIR ❑ TH11 analysts <br /> PUMP INSTALLA DISPOSAL FLD. PFiB �E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �----- PITS/SUMPS <br /> FOUNDATION � — AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> i 7 Industrial ❑ Open Bottom ❑ Manteca Dis- of Well Excavation Specifications <br /> ' Type of Casing <br /> C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Depth al Grout Seal Type of Grout [� <br /> ('1 Public Ia Other f` n Delta ", �' <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seaf Installed by O <br /> of Pump H.P. State Work Done <br /> Repair Work Done t J Type I Sealing Hate�ri�a1 � Depth. <br /> Well Destruction 0 Well Diameter -- - <br /> "� Depth Filler Material & Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION ! I available�w thin 206 feetstem .) if public sewer is <br /> Installation will serve: Residence i Commercial— Other.�--- <br /> Number of living units: Number of bedrooms <br /> MP <br /> depth <br /> Character of soil to a depth of 3 feet: ments <br /> SEPTIC TANK. ❑ Type/Mfg Capacity <br /> isposal <br /> PKG. TREATMENT PLT. ❑ Pr <br /> k Distance to nearest. Well Foundation <br /> I j <br /> Total leng <br /> LEACHING LINE ❑ No. & jenglh of lines Property <br /> FILTER BED El Distance to nearest: Well Foundation <br /> SEEPAGE PITS 11 Depth I Sire Number <br /> SUMPS Ll 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 done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> e following: "I certify that in the performance of the work for which this permit is issued, 1 shall <br /> Home owner or licensed agent's signature certifies thnot <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the followin "I certify that in the pertarmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif nia <br /> The applicant ust II 10 Il uire s coons. Complete drawing on reverse side. <br /> - C-ark R. Bexn�tt <br /> Title: Envirbfimnta Services Tech. Date: <br /> Signed X <br /> GOR DEPARTMENT USE ONLY <br /> Date <br /> Application Accepted by � �y( <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Data <br /> Additional Comments: <br /> } Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK RECEWE0 6Y DATE PERMIT'NO. <br /> FEE <br /> MOUNT DUE AMOUNT REMITTED CASH <br /> �/�� �/� <br /> a EH 13-244AEV.I/R51 INFO [/r/ N/ /• V� � � TZ-OA <br /> EH 14.20 �If <br />