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APPLICATION FOR PERMIT <br />i <br />This <br />l—(!> ms & feD 3/l6^4g-5Citv Lot Size/AcreageJob Address <br />Owner's Name VAL- /IS,5<?Cz'/17~<S£AddrRss Phone <br />pLcyp g, LUcciH Phone <br />TYPE OF SEPTIC WORK: <br />(e) IT-cro <br />Capacity / <br />7Distance to nearest:•2-0Well <br />Well Foundation <br />7 r?fFoundation <br />Signed X.- 7/Date: <br />t FOR DEPARTMENT USE ONLY <br />Application Accepted by Date <br />Date <br />&€Additional Comments: <br />Applicant - Return all copies to: <br />95201 <br />AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br />///^7/^^5j3o3f lUTOl <br />.Size <br />Well <br />Lo" <br />I so i-Distance to nearest: <br />• EH 13-24 (REV. IZH SI <br />EH 14-2S <br />LEACHING LINE <br />FILTER BED <br />Application ia hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. <br />and Regulations of San <br />C No. & Length of lines <br />Distance to nearest: <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. HAZELTON AVE., PHONE (209)468-3420 <br />P O BOX 2009, STOCKTON, CA 95201 <br />Total length/size____ <br /> Property Line <br />Number <br />Property Line <br />______Water table depth _ <br /> No. Compartments <br />Method of Disposal <br />Property Line '2-0 <br />Dia. of Well Casing <br />Specifications_____ <br />Type of Grout <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />FEE <br />INFO <br />Contractor <br />TYPE OF WELL/PUMP: <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation <br />Type of Casing <br />Depth of Grout Seal <br />Surface Seal Installed by______________ <br /> State Work Done <br />TYPE OF WELL <br /> Open Bottom <br /> Gravel Pack <br />1'1 Other <br />Approx. Depth <br />Type of Pump <br />Well Diameter <br />Depth <br />NEW INSTALLATION IT <br />Address 7 <br />NEW WELL <br />PUMP INSTALLATION <br />DISTANCE TO NEAREST: SEPTIC TANK <br />FOUNDATION <br />WELL REPLACEMENT <br />SYSTEM REPAIR <br />SEWER LINES DISPOSAL FLD. <br />AGRICULTURE WELL OTHER WELL <br />License No. <br />DESTRUCTION Out of Service Well <br />OTHER Monitoring Well <br />PROP. LINE <br />PITS/SUMPS <br />PROBLEM AREA <br /> Manteca <br /> Tracy <br />D Delta <br />I I Eastern <br />H.P. _ <br />Sealing Material It Depth <br />Filler Material i> Depth <br />REPAIR/ADDITION)^ <br />INTENDED USE <br /> Industrial <br />Cl Domestic/Private <br />Cl Public <br />I I Irrigation <br />Repair Work Done <br />Well Destruction <br />(7 <br />0 <br />application ia made in conqrliance with San Joaquin County Ordinance No. 51r9 and 1062 and the Rules <br />Joaquin County Public Health Services. <br />____________ Date______Pit or Grout Inspection by <br />SEEPAGE PITS Depth <br />SUMPS LI <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 />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 I shall not <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 />don lais o’f 23 '' Cer,',V ,hal in pertOr'T1flnCe 0*,h8 work *or which ,hi8 Perrnit *» iMued- 1 shal1 •mP,°Y persons subject to workman's compensa- <br />The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Title: . <br />Installation will serve: Residence Commercial L Other <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: (2-^- /I / <br />SEPTIC TANK Type/Mfg P^L- <br />PKG. TREATMENT PLT. <br />------------------- ------------- Area _ <br /> Final Inspection by \ /.VvWr <br />8an Joaquin County Public Health <br />Services, Environmental Health Permit/Servicea <br />1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA <br />CK i <br />CASH <br />DESTRUCTION I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />/ Foundation