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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COONTY. PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 'PERMIT ATE T iaTfl D <br /> (Complete in Triplicate) <br /> Application is hereby aeede to Ben Joaquin County 'or a permit to construct and/or install the work herein described. This <br /> ApplicJoaquin Coo is Pude in a Health <br /> cos.vith Sao Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of Sun <br /> Joaquin County Public Health t3et�vices. - <br /> 't <br /> Job Address <br /> ... ..-._._ .._ <br /> Cit y Y'�-J----xi.�-'�-�.... Lo.t.»b-S_ze/Acrege <br /> Owner's Name k,, Address v <br /> . -.__.. <br /> -- J^ Phone <br /> Jn <br /> Conlractor.A L.. J(t t �' Address _ — I <br /> License No.c�� Phone <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT i 7 DESTRUCTION Ci out 03 Service we11 ❑ <br /> PUMP INSTALLATION L7 SYSTEM AEPAIA ❑ OTHER G Monitoring Wen � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE •� <br /> ` FOUNDATION AGRICULtORE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE = TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r• � .. <br /> n industrial E Open Bnttnm C7 Manteca Dia. of Well Excavation Glia. at Well Casing <br /> t7'Domestic/Ptivate Ci Gravel Pack., 0 Tracy Type of;rasing _ Specifications <br /> t'1 Public I:1 Other t _ .. •, , <br /> t , f l Deas Depth of out Seat TYpe of Grout r <br /> i ! Irrit-,.atiori Approx. Depth I I Esstern Surface Saul installer)by . <br /> Repair Work Done a Type of Pump ' t H.P, State Work Done <br /> Wall Destruct \. ❑ Well Diameter Sealing Material i Depth t <br /> t <br /> Depth_ Filler Material i Depth i <br /> TYPE OF SEPTIC WORK:,.NEW INSTALLATION REPAIRYADOiTION i I DESTRUCTION i IutNo naptic system permitted it public sewer is � f <br /> ` available within 200 feel.) <br /> Instaflarion will serve: Resirienca _c.Cornmercinl"r. Other <br /> Number a1 Gving units: Number of bedrooms - <br /> Character of;toil to a depth of 3 teat: Water tactile depth{- <br /> SEPTIC TANK 1 ,�f ypalMig _`} L 't Capiteity_ No. <br /> ^�:.._.. irafYlpartr'nant;._. . <br /> PKG. TREATMEN7'PLT.M t Method of Disp�ss1 ` <br /> istance to nearest: WeIA --- _� Property Lin* <br /> . 7(W I <br /> I �R Foundation ' <br /> LEACKNG LINE No.& g <br /> Len th of lines._ <br /> FILTER BED ' ° Total length/size <br /> n <br /> istbnca to nearest:. Walt _"po_41.ndatiort, lJ Property tine <br /> i } ,^ �.. r <br /> SEEPAGE PITS1 t Depth tY Sita _ ! __` NurJsbei <br /> SUMPS D;stance to nearest: <br /> well • Foundation,—. Proo" Line <br /> DiSPO5AL POh1D5 <br /> i <br /> t hereby certify that I have prepared this application and that the work will be none in accordanca with San Jo <br /> rules and regulations of the San Joaquin County again county ordinances, stew laws,and <br /> Homs 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 sub)ect to workman's compensation laws of California."Contractor's hiring or subcontracting signature !!! <br /> certifies the following: "I tarxify that;n <br /> California."Ca <br /> tion taws of fo the P'l"I drics of the work for;which this permit is issued.I shall employ persons subioct to workman's compensa- <br /> The applicant must call tot all r quirad'inspactions, Complete drawing on reversal side. <br /> Signed adzT <br /> itle: ` �\ <br /> �:. 1�-�-''1 `,. Data: <br /> �' C1iI DEPARTMENT USE OfitLYX✓' <br /> Application Accepted by � <br /> ©ata t Area <br /> Pit or Gra Inspection by y, 1 <br /> Date Final Inspection by Date <br /> Additional Comments: - <br /> Applicant Return all copiers to: San Joaquin Cotuaty Public Ae 1th \ <br /> Services, Btvirotstaental health Permit/Services <br /> 1603 E, H"alt" Ave,,1P 0 Box 2009. Stockton. CA 95201FEE , - <br /> INFO AMOUNT Ot1E AMOUNT AEMiTTED't CCx <br /> ASH ,' r <br /> yj� ,, RECEIVED BY.• OAt•E PERMITNO,_ <br />