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f� <br /> " APPLICATION FOR PERMIT <br /> j SAN ..,AQUIN COUNTY PUBLIC HEALTH &,AVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> g 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> E <br /> PEWIT EXPIRES ] FROM DATE ISSUED <br /> (Complete in Triplicate) p� <br /> 4 Application is hereby made to San Joaquin County fora permit to construct and/or ins Il'u- <br /> h �Q+escf.Ybed. This <br /> N I+ and 162 Re tions of San <br /> application 1■ Hale in cer�liance tritk ion Jeatulrl Ceuaty Eriinsnce e 5 ! • Lnl+ <br /> I' Joaquin County Public Health Services. <br /> Job Address ✓ , °� City G I Lot Size/Acreage <br /> E`f ° <br /> l Owner's Noma — Address <br /> �JPhone <br /> �'. Contractor a Address n "`� License No.r7OS?j-1 Phone T 3 <br /> EI TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Hell 0 <br /> j; PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> P 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing Specifications <br /> a [ tf I'l Public. f.1 Other n Delta Depth of Grout Seat Type a1 Grout ( A <br /> # I I ifrigation _Approxi Depth t I Eastern Surface Seal Installed by \J <br /> r Repair Work Done U Type of Pump H.P. State Work Done_ <br /> ill _ <br /> -,We" Destruction 0 Well Diameter Sealing Material i Depth <br /> Ej <br /> Depth Piller Material i Depth <br /> t Ei c TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION!T DESTRUCTION I ] {No septic system permitted if public sewer is <br /> available within 200 lost.1 <br /> f# - Installation will servo: Residence Commercial Other <br /> Number of living units: Number of bedrooms 9 �6 <br /> Character of soil to a depth of 3 feet: �" `� __Water table depth <br /> SEPTIC TANK ItY Type/Mfg `—C -- Capacity E/b y <br /> No. Compartments .� <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> I 1 <br /> i! Distance to nearest: Well Foundation Property Line <br /> t <br /> r LEACHING LINE PNo. S Length of lines Total length/size ' <br /> g FILTER BED D Distance to nearest: -Well to '_ FoundatioRig!PProperty Line <br /> SEEPAGE PITS 14 Depth Size 47(e ., Number - <br /> SUMPS s Ll Distance to nearest: Well 1:20-1-_ Foundation g4&0I Property Lina r <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 Mm 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 subcontracting 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 componsa• <br /> tion laws of Californlo." <br /> The applicast call for all req 'ed I tions. Complete drawing on reverse side. <br /> _I Signed X7 � � rale: Alr�aj_C.di Date: <br /> �Q�= �Z• <br /> • FOR DEPARTMENT USE ONLY <br /> i � --� <br /> g <br /> Application Accepted by w Date 7� 9 2 Area �-77 <br /> Pit or Grout Inspection b Date Final Inspection by Oats <br /> j <br /> Additional Comments: <br /> Applicant -.Return all copies to: San Joaqu n County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE13-24 IR Lff <br /> UE AMOUNT REMITTED AS CEIVED BY DATE. PERMIT'NO. <br /> INFO f <br /> EH 14.2 // <br />