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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES k <br /> < ENVIRONMENTAL HEALTH DIVISION i <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 4-3CaU R ?RQM DATE 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 /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Josquin County Public Health services. �� _ ��7,1r+ <br /> 1 '4`Z. �l2�Gi S7 Citywp`�"'�/Ar Lot Size/Acreage <br /> Job Address I <br /> .�Gl Phone 33 <br /> Owner's Name Address i <br /> c G u 'Lf <br /> 456L9 Address 6 y2 `~x License No� �r _Phone �r Y� <br /> • Gontractor/�r�� - <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION t of Service Well Ll <br /> Monitoring Well C1 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - "DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL �` 4'' OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL""-f ROBLEM�AREA.•CONSTRUCTION-SPECIFICA7lONS- <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1/C Specifications <br /> I Woomesfc/Private `Gravel Pack ❑ Tracy Type of Casing �- <br /> M Public Cl Other 0 Delta Depth of Grout Seal 1dc7 Type of Grout <br /> M irrigation L.S'0^Approx. Depth ❑ Eastern Surface Seal'lnstalled by - <br /> Repair Work Done U Type of Pump Sk H.P. f State Work Done—04"rJJ­tx_ --- <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth ]Tiller Material i Depth <br /> TYPE OP SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION 0 DESTRUCTION Cl INo septic thin system rmit'ed if public sewer is <br /> avaI ` <br /> Installation will serve: Residence..,—. Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to's depth of 3 feet: Water table depth <br /> i SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> kPKG. TREATMENT PLT.Cl"`— t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t t <br /> rF LEACHING LINE ❑ No. &tLength of lines / yTotal length/size <br /> FILTER BED r—Fl Distance to nearest: Well Foundation t - Property Line <br /> i t �" ' <br />�- - SEEPAGE PITS11 Depth I Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS;. e.E7. <br /> I hereby certify that I have prepared this application and that the work will be done in acc6rdance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County f r <br /> ►come owner or licensed agent's signature cenifies the following:`•I certify that in the performance of the work for which this permit is issued, I shall not <br /> I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cenifies the folto*4 "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 /> r. <br /> The applicant must call for all re uired inspetctioris,FComplete drawing on reverse side. <br /> Signed X __ __ Title - Date: <br /> i <br /> i I F R DEPART IIRENT USE-ONLY '] <br /> t CMS r r Date fl`�� Area <br /> Application Accepted by , <br /> a <br /> Pit Grout I spection by - Date Y �� Final Inspection by �a �� Date <br /> Orr7 z <br /> Additional.Comments: �u. R <br /> Applioarit y Return all co" ee to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH"DIVISiON PERMIT/SERVICES /�¢�cl.•9Ie <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 ((( <br /> IFEE NFO I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. <br /> . EH 13-24 fREV.IlKS1 <br /> EH i47a <br /> �_37�; - ffW 9 1-nd <br /> k f <br /> f <br />