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APPLICATION FOR PERMIT <br /> r <br /> IL, SAWN JOAQUIN COUNTY PUBLIC HEALTH_S�RVICES <br /> ENVIRONMENTAL HEALTH DIVTT 40% <br /> f 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> jr P O BOX 2449, STOCKTON, CA 95201 <br /> I r S (Complete in Triplicate)o©�S�b� 204 - 1'7o--ea3 <br /> Application is heretay side'to Sati n County for a permit to construct and/or insure the work hereih described. This <br /> application is made in compliance with Bari Joaquin County Ordinance No. 549 and 1862 and the Rales and Regulations of San <br /> {i Joaquin County Public Health Services. <br /> `S Job Addras$ uT�(h City © s �1(4C Lot'Size/Acreage 35MQc_r45 <br /> r <br /> Ph <br /> Owner'a Name Address $12c� Tim[ R u�ft Qi3�o-[S�oQ <br /> Phone <br /> Contractor W94� _ _ Address r()._%%. License No.CS?- 5'��19 nP <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service k'e11 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C) &A-d- I OTHER a Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENOEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> , <br /> 0 Industrial ❑Open Bottom ❑ Manteca Die, of Well Excavation pia. of Well Casing <br /> fn Domesliciplivate 0 Gravel Pack ❑Tracy Type of Casing Specifications <br /> I'1 Public 1-1 Other r Delta Depth of Grout Seal Type of Grout <br /> ! !Irrigation —.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done Ll Type of Pump H.P, State Work Done �1^ <br /> Well Destruction 0 Well Diameter Sealing Material & Depth :h j <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION I I REPAIRlADOITION l I DESTRUCTION I I INo septic system permitted if public sewer is <br /> 1 Installation will serve: Residence— Commercial_ Other available within 200 fast.) <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 PLT.❑ <br /> Method of Disposal ' <br /> Distance to nearest: Well Foundation Property Line <br /> ` LEACHING LINE ❑ No. 8 Length of lines Total length/site <br /> FILTER BED 0 Distance to nearest: Wan Foundation Property Line <br /> r <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundition 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,ander <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent'a 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 /> certifies the following:"I certify that in the performance,of the work for which this permit is issued,I shall employ persons subject to workmen's eompensa- <br /> lion laws of California." <br /> The applic n ust call for equ d Inspections. Complete drawing on reverse side. <br /> Signed k <br /> Title: � -' Date.• 3190 <br /> j <br /> FOR DEPARTMENT USE ONLY r� / <br /> 14 <br /> Application Accepted by Dete ^vu 2 <br /> tea <br /> Pit or Grout Inspection by ata Final Inspection y Oats 'Zv <br /> Additional Comments: f q <br /> Applicant - Return all copies to: Ban Jcaqu n County Public Health UUv4tli(e `ii uf?1'4 <br /> Services, k=viroamental Health Pe tlServices ieG ti <br /> 1601 S, Hazelton Ave., P 0 Box 2009. Stockton, CA 1015201 �O ��'` 1•��r <br /> FEE AMOUNT OVE AMOUNT REMITTED <br /> INFO C RECEIVED SY DATE PERMIT'NO. <br /> . EM 13-24 IREV.V1151 ♦1 p <br /> FH;4.28 <br />