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APPLICATION FOR PSRI[IT A ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 � 0 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT_E%PIRES 1 YEAR FROM DATE I$SUED � 0A A` <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 campliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health ,Services. <br /> Job Address ' _� _��` `�� a �' /L -yl-- -- Clty `� � `l Lot Size/Acreage �� er <br /> ?,owner's Name !fig- Z __`'/C CO ZZ 4L`1 Address AE70 C11--e1-10';5:e'2 <br /> XContraclor � Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1. <br /> 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dis. of Well Casing <br /> 0 Gravel Pack O Tracy Type of Casing ` Specifications <br /> 1. Cl Domestic/Private <br /> -1 Other-. .. —,.f7 Delta—___- Depth of Grout Seat � Type of Grout • <br /> M I I Irrigation Approx. Depth I I Eastern Surface Saul Installed by p3 <br /> `Repair Work Done L7 Type of Pump H.P. State Work Done V <br /> Wall Destruction O Well Diameter Sealing Material 4 Depth <br /> # \ Depth biller Material i Depth t 3 <br /> 3 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTIONINo septic system permitted if public sewer is <br /> +3333 available within 200 feet.! <br /> Instslllation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of salt to a depth of 3 feet: Water table depth <br /> t <br /> SEPTIC TANK. ❑. Tips/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT.QMethod of Di <br /> sposa! <br /> Distance to nearest: Well Foundation Property Line '� <br /> LEACHING LINE'1 0 No. & Length of lines Total length/size r <br /> FILTER BED 0 Distance to nearest: Wall Foundation Property-Line i <br /> SEEPAGE PITSI Depth Size Number <br /> t r <br /> SUMPS,., 'r ��L-I l Distance to nearest: Well Foundation ! PropertyaLina <br /> DISPOSAL PONDS �A, o <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 <br /> Home owner or licensed ageni'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 man'ner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shafl employ persons subject to workmen's-compensa- <br /> tion laws of California." \\ <br /> The applicant roust call for Mt requited inspections. Complete drawing on reverse side. <br /> XAWned Title: Date: <br /> F R DEPART ENT USE ONLY <br /> i <br /> Application Accepted by y Date Area <br /> +a / <br /> Pit or Grout inspection by 1 Date `Find Inspection-by Dath <br /> Additional Comments: L 0^_ <br /> Applicant - Return all copies to: Ban Joaquin County Public Health Services <br /> -= d --- Environmental Health-Permit/Services— �57%� <br /> 445 N San Joaquin, P O Box 2009, Btkn, QA 95201 <br /> IINNFO FEE AMOUNT DUE AMOUNT REMITTED CK <br /> +} CLASH RECEIVED BY DATE PERMIT'N0. _ <br /> . EN 1}2♦tREV.rrtiai ✓ t�� t�1�3 r.�p 1 �� <br /> EM t�•2e <br />