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/ 3 � APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> '`1rry T <br /> pxMil-miggs :L YEAR rRou :! l <br /> G <br /> (Complete in Triplicate)U .; <br /> Application ie herby made to San Joaquin County for a permit to construct and/or install the work herein described. Thisw, f <br /> application Is made in c=Wllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servicee. <br /> ,Job Address "3f0'C " ! _ / City �.ot Size/Acreage <br /> ' owner's Nam7 C� Address Phone i <br /> �✓P,.dFdr ss Y_ _FG-/ 6f?-:�' <br /> TYPE OF WELL/ P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 't of Service Wazi a❑ '� <br /> STALLATION M T SYSTEM REPAIR ❑ OT 13 Monitoring Well ❑ ` <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPCSAL-=F^M, �PROP_._LINE: <br /> FOUNDATION RICULTURE WELL 0 WELL PITSISUMPS <br /> N t <br /> INTENDED USE TYPE OF WELL PROBLEM,ARE_A NSTRU ,SPECIFICATIONS-- ` '{ " f, e <br /> Ll Industrial ❑ Open Bottom O Manteca Di Excavation Dia. of Well Casing <br /> U Domestic/Private D Gravel Pack ❑ Tracy Type of Casing _ _ ^� Specifications <br /> M Public 1-1 Othera Depth of Grout Seal Type of Grout <br /> CJ Irrigation _.Approx. D ❑ Eastern SuHa'ce Saul Installed by <br /> Repair Work Done U Type mp H.P. State Work Don _ i <br /> Well Destruction ❑ ell Diameter Seealing Material & Depth <br /> Depth Filler Material & Depth <br /> /TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIRIADDITION M DESTRUCTION CI (No septic system permitted it public sewer is <br /> available within-20D feet.l <br /> Installation will serve: Residence 4 Commercia Other <br /> Number of living units: —4 Number of bedrooms <br /> Character of soli to a doptV 3 feet. _ r Water 1a61e de th j <br /> --r-t 51 <br /> SEPTIC TANK: Type/Mfg <br /> G w C�_e.14 - cbpa�rty_- -- '„"'fro Gom artments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal {' <br /> Distance to nearest: Well Foundation -Property Line <br /> LEACHING LINE No. & Length of lines "' d Total lertgth/size + <br /> FILTER BED AT Distance to nearest: Well Z60 FoundaXXtion `Property Line ry" <br /> SEEPAGE PITS $<r DeplhZL Size ja 2'E1,4• Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line 'i <br /> DISPOSAL PONDS ❑ rss t <br /> I hereby cenify that I have prepared this application and that the work will be da in accordancekwiih 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 carlity that in the perfo nance 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 /> 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 applicants must call for all r irad inspectio s. omplete drawing on reverse side. / <br /> Signed XG,�`rQ/j� i -��'C Till a: J_�� /sate: <br /> F DEPARTMENT USE ONLY �{ <br /> Application Accepted by _ e,.�+�rt� Date <br /> Pit or Grout Inspection by Date Final Inspection Dats <br /> t <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y" w <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES .+ <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 85201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED / CASH {�R�ECEIVED 8Y PATE PERMIT NO. <br /> . EH 13.24 TREY.riw51 ` 1L"� .2� 1 <br /> EH,4' 11 W t r <br />