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_ APPLICATION FOR PERMIT <br /> �� r s ell <br /> I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION A <br /> ` P O BOX 2009, STOCKTON, CA 95201 a <br /> cc—elr (249) 468-3447 <br /> II��f aPERMIT Y <br /> YEAR( I �pc7 t <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 /> application is made in compliance vith S%n Joaquin County Ordinance No, 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health,Sery1ces-. <br /> Job Address tai. City t •t Lot Size/Acreage <br /> Owner's Name {�6' Address an1k, _ Phone Q—71,53 <br /> Contracto Address R License No._!53nJQ2 2..Phone7 7 <br /> a <br /> TYPE OF WELL/PUMP: NEW WELL_ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION Gel SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well i7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ,�p� SEWER LINES DISPOSAL FLD, PROP. LINE/2_1Q� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL s OF PITS/SUMPS <br /> INTENDED USE TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> n Industrial pen Bottom L3 Manteca "Dia. of Well Excavation Dia. of Well Casing <br /> V60mestic/Private O Gravel Pack ED Tracy `-Type of Casing _ Specifications. r <br /> G Public ("3 Other ❑ Delta Depth of Grout Seal Type of Grout. Q <br /> C! Irrigation Approx. Depth 0 Eastern Surface Seai Installed by <br /> Repair Work Done U Type of Pump b H.P. I State Work Done _ <br /> Welt Destruction O Wall Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORTS: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION GI INo septic system permitted it public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence` Commercial Other <br /> r <br /> Number of living units: Number of bedrooms <br /> Character of soil toga depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartment <br /> PKG. TREATMENT PLT. C7 F -' Method of Disposal <br /> - = t <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED i -CI Distance to nearest: Welt Foundation Property Line r <br /> SEEPAGE PITS 11 Depth Size Number ' <br /> SUMPS LI Distance to nearest: Well Foundation 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, and ! <br /> rules and regulations of the San Joaquin County r <br /> Home owner or licensed a ent's si nature cenifies the followin <br /> g 4 g; 'I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any parson 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 workman's compensa• <br /> tion laws of California." <br /> The applicant must call for H-rrequired inspections. Complete.drawing on reverse side; I i <br /> ,. <br /> A. <br /> t G T � <br /> Signed k Title: � Date:-_ � <br /> 1 <br /> FOR DEPARTMENT U ONLYq <br /> Application Accepted by Date Area ©� <br /> i � <br /> Pit or Grout Inspection by Date 9 7 Final Inspection b Date 10^1 <br /> C1 <br /> Additional Comments: <br /> Applicant Return all copies to: AN jOAQUIN COUNTY PUBLIC HEALTH SERVICES — <br /> \\�- ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE C <br /> AMOUNT DuE AMOUNT REMITTED ASH <br /> t F CARECEIVED BY DATE PeAMIT'NO. <br /> . � <br /> \. � �,.� <br /> . EK,].24IttEV.li61 -131 7 <br /> I .D t7 !3 ve l "-cf2 <br /> e <br />