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4 <br /> ~ APPLICATION FOR PERMIT ..- <br /> S JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> AUG 21 199@601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 9A \"3p8 .. 9 <br /> 3- <br /> ENVIRONMENTAL� ES EXPIRES 1 YEAR FROM DAT ED <br /> PERMITI (Complete in Triplicate) <br /> Application is hereby made to San JW74 UVIc work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Re l.ationa of San <br /> Joaquin County Public Health Services. �/v 161—4019—OZ f 05_J "/V 7x/-4016_400 /�,¢/O <br /> Job Address 1` (�4tm P City ST�s/�? Lot Size/Act e ­0q-06 <br /> Owner's Name�31�.1Ty! LYD/v5 la 1 /?9O1p75$ Phone ai 66 <br /> Contracto 5 <br /> tN s Z::�2,5�_ air ff1Y2�-+F License No.9'j7_7 Z6S5Ptone <br /> TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 9 �� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial f1 Open Bottom I-) Manteca Dia. of Well Excavation —Din M lemu resit;,,,, l/=TiT _Ml <br /> C1 Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing _1gWx4LWVgAs <br /> I'} Public f:] Other f1 Delta Depth of Grout Seal T;�=;a �/Ist 8 it:- <br /> I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> of c� <br /> Repair Work Done 0 Type of Pump H.P. State Work Done � _ {� �ilLl <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is (Q <br /> available within 200 feet.i <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PET. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line C <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS El 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 /> rulas 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," Contractors 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 m call for all required insAections. Complete drawing on reverse side. <br /> Signed Title: 6FLvG9 9"eI=Q 61&T Date: <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by Date_ (1� �~ZO Area <br /> Pit or Grout Inspection by Date Final Inspection by Date J--2A-9(d C7 <br /> Additional Comments: Vf <br /> d 7 O! <br /> t <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> ASH RECEIVED BY DATE PERMIT'NO. I <br /> • EH 13-26 24 lRE1l.i iH s) <br /> 11 /��` Q..'].-35 <br /> EH . <br /> v <br />