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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-5447 <br /> 1 11114 - <br /> �I?�1"t /Lt�r `jv`Isr (C )(mplete Triplicate) <br /> �✓ <br /> Appiicativn is hereby mndc t Sea Joaqu county for <br /> OrdinancerwitAo struct No. 549Bando18628tall and thee work Rules andein described.Regulations of Sana <br /> app cation is made in cezpliance with San q , <br /> J <br /> in <br /> CotuttyPulic Health Services. <br /> City 4409e Lot Size/Acreage <br /> I <br /> LbAddress <br /> Address — Phone <br /> �3S <br /> er's Nam p' <br /> icense No. Phone <br /> Contractor f� Address <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Out Mo Service dell C] <br /> �� 0TH ❑ Monitoring Well U <br /> PUMP IINSTALLATION ❑ SYSTEM REPAIR 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — <br /> DISPOSAL FLD. PROP. LINE <br /> FOUI�DATION ._ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S <br /> -- --�r "— Dia. of Well Casing ` <br /> n Industrial Open Bottom ❑ Manteca Dia, of Well Excavation' Specifications t <br /> CJ Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing <br /> Public <br /> I'l Ol ger CJ Delta Depth of Grout Seal Typa.of Grou <br /> - <br /> �I IrriOation Approx. Depth CI Eastern Surface Seal Installed by <br /> Repair Work pone 0 -Type of Pump H.P. State Work Done <br /> — Sealing Material i Depth / �j <br /> Dept <br /> Weil Destruction X Weil Dia er �— / Piller Material i Depth ��^ 2�/ <br /> h t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L❑ REPAIRIADDITION iii DESTRUCTION CI INo septic system permitted if public sewer is i <br /> III available within 200 feet. <br /> Installation will serve: Residelnce Commercial — Other <br /> Number of living units: �! Number of bedrooms <br /> w ato�dapth <br /> /J <br /> Character of nail to a depth of 3 feet: <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ F- Method of Disposal — r <br /> DiM ante to nearest:~ Well tion Property Lina <br /> LEACHING LINE Cl No. & Length of line l langthlsi:e <br /> FILTER BED ❑ Distance to est: Well Foundation my <br /> Li <br /> I <br /> SEEPAGE PITS 11 pt Sire Number tY} <br /> I <br />' SUMPS Li Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ ,��. <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stela laws, and <br /> rules and regulations of the Sari`Joaquin County <br /> Home owner or lice sed agent'sEsignature cervi' s the following: "i certify that in the performance of the work for which this permit is issued, I shell not <br /> emjymn such manner as co aubieci to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> Ceg: "i certify that' the pe rmanae of the work fpr which this permit Is issued, f shall employ parsons subject to workman's compensa <br /> tioia."Thcall for all rl r ctiona. Complete drawing on <br /> Sig <br /> Title: Date: r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection by Data final Inspection by_0 Dat <br /> Additihnal Comments: I� — <br /> Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES s. <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS <br /> RECEIVED BY DATE FtAMIT'NO. ` <br /> INFO <br /> + EH 13'74 IttEV 5) <br /> EH 1{.2a <br />