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it <br /> APPLICATION'POR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SbAVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 R. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> R [!ED <br /> (Complete in Triplicate) <br /> Application is hereby Slade to Sam Jorgnia County for a permit to construct and/or ia1tall the vork herein described. This <br /> application 1e made In compliance vtth San JoaQuia County Ordinance No. 5+9 and 1062 Lad the Rules and Regulations or Sam <br /> Jcwgvin County Public Health Services. <br /> Jab Address 54r10 EAI'+ F7�f✓1Q.�. Ld,v,-e City I-001 Lot Size/Acreage 10Id <br /> s Owner's Nam. Cv1o� 5�at Ir Address 5400 Ent 4' Qw L-e_PRon, z.a9 SvS-OZ7.15 <br /> 9yb7I <br /> Contractorw ESTE Address uu. 'SAC-.. icense NO-t5 .198 Pnone il6 3 13-11 i <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C DESTRUCTION Q Oat or Service Well ❑ <br /> PUMP INSTALLATION CO SYSTEM REPAIR ❑ OTHER ❑ Monitoring Hell <br /> DISTANCE TO NEAREST: SEPTIC TANK 222 .SEWER LINES 41A DISPOSAL FLD: UA PROP.LINE tap ,r*. <br /> FOUNDATION AGRICULTURE WELL 155 .OTHER WELL -alp?-�PITSISUMP$ MI <br /> t INTENOEO USE _TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS r <br /> t Intlustr:a: 11fC...,,,3���Open 8ottorn G Manteca Dia.of Well Excavation—III Dia.of Well Casing ra <br /> i <br /> IN Domestic/Private }tp Gtaval Pack 0 Tracy Type of Casing :1 40 PV C- Specifications <br /> h i Cl Public Ia Other fl Della Depth Of Gratis Seat f '- S-14" Type of Grcut <br /> 1 <br /> 1.1 Iifigalion APprox. Depth /I I Eas it Suri a Sout Installed by _f'r <br /> " Repair Wark none p Type of Pump P`A H.A. Surq Work pone_ f1 <br /> 'NeDestruction ❑ Well Diameter r Scaling -al • Depth <br /> O �� Filler Material iDepth '3yat3.r{1-f ON—pt 4JaO--.J°oS+.'k.Mart�,rDepth 11 / <br /> , <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo sepNa system permuted it public sewer is <br /> j 'l1 :.vailabte within 2O0 feet.l - <br /> 3;: Installation Residence, Cammareial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of$ail to a depth of 3 <br /> 4 „_W Is depth <br /> SEPTIC TANK 0 T /Mf i <br /> f ype 4 — ,�CepaciN No.Compartments <br /> PKG.TREATMENT PLT.❑ <br /> Method of Disposal <br /> Distance to nearest: Welt Found Property Line <br /> f <br /> LEACHING LINE ❑ No.E Length of lines Total langth/size i <br /> ! FILTER BED C7 DistancaI . est: Well F <br /> Fpundahon�� Property line <br /> 0 <br /> SEEPAGE PITS 1 Depth Siva Number <br /> 6 SUR4P5 LI Distance to nearest: Well Foundation Property Lina J <br /> ! OtsP L PONDS E3 <br /> { - k hereby certify that I have prgparw7 this application and that the work wilt be done in accafdancr,with Sin Joaquin county ordinarces,stain laws,and <br /> 11 ,� rules and reputations of the San Joaquin County <br /> Home owner or licrnsed agent's stgnalure certifies the following;"I certify that in the p&rformance of the work for which this permit is issued,I shall not <br /> employ any person In Such manner as to become subpct to workman's compensation laws Of C81 0fria."Contractor's hiring or subcontracting Signature <br /> 7 1 certifies the following:"I certify that in the performance of the work for which this permit 1s issuad,I!mill employ parsons subject to workruNt compensa• <br /> tion Owe of California."/ <br /> rF ~ Tha sppGca`s mAsy��f.�eaRr.au'uedfi spent�j L drawing an rwer/se`sine. _ <br /> til Signed Data: <br /> FOR DEPARTMENT USE ONLY <br /> t I APPlicabon Accepted bY_—_. Araa- ---- <br /> t l <br /> Pit or Grout Ins �- <br /> 1 <br /> i <br /> Paot:on by pat& final Inspection by Der ; <br /> ddidnnal Commonts: _ - <br /> "Applicant -'Return all copir>• to Sea Joaquin County Public Health <br /> _ Services, Enytrommeatal Health Persil/Services " <br /> 1b01 E. Easeltaa Ave., P 0 Ilox 2009. Stdcktom, CA 95201 <br /> EE <br /> INFO AMOUNT DUE aMgUNT REMITTEa�CK 3 <br /> —CASH RECEIVED By DATE PERMWNO, - - <br />