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APPLICATION FOR PERYITV <br /> •'- _,r+ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONuENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCBTON, CA 95201 <br /> PERMILT =I -R ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> appliCst:ion is wide in eonplisnce with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public health Services. <br /> 13 krAs <br /> Job Address City Stn tGa _ Lot Size/Acreage <br /> Owner's Name Unipit TcP Address 1370 W. NgberPhone <br /> 90=3 231 <br /> Contractor Om�'� i—&ter=igft?-9 Address License No. 01079 _ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER JV Monitoring Melt <br /> G�1 Vapor Stiirv�y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PRt3P. L E <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> O Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel Excavation Dia. of Well Casing 0 <br /> [.I Domestic/Private ❑ Gravel Pack © Tracy Type of Casing Specifications <br /> 11 Public 1:1 Other n Delta Depth of Grout Seal Type of Grout [ <br /> I I beigadon —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Done <br /> Wal Destruction ❑ Wel Diameter Sealing Material i Depth <br /> Depth biller Material ii Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Instaletion will serve: Residence— Commercial_. Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg ti Capacity No. Compartments <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Wel Fo tion Property Line <br /> It AANX <br /> LEACHING LINE CI No. fi Length of I' Total length/size <br /> FILTER BED ❑ Distance to nearest: Foundation Property Line _ <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby osnify 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 /> Homs owner or licensed open's signature candies the following: "I certify that in the performance of the work for which this permit is issued, i shall not <br /> employ my person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-coatraeting signature <br /> certifies due following:"I certify that in the peMormance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of C40orMs." <br /> The applicant t cal for all required inspections. Complete drawing on reverse sips. <br /> � �c7 <br /> Sigma Title: Date: O <br /> AORDEPARTMENT USE ONLY <br /> Appkadon Accepted by sukwxwe <br /> f 19 Date Area _ <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Appliesnt — Return all copies to. San Joaquin County Public Health <br /> Services, Eaviranmental Health Permit/Services <br /> 1601 S. Raselton Ave.. P 0 Bou 2009, Stockton, CA 95201 <br /> PEE AMOUNT DUE AMOUNT REMITTED RECEIVEO BY DATE PERMIT'NO. <br /> WO C ry j//� f <br /> r EX 13-34 OW,t!asl �/ `s"� 3 w •O V / IS-1S <br /> fat t&i <br />