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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) 468-3447 <br /> 2EMIT .EXPIRES _I YEAR SROM 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 /> Joaquin County Public Health Services. <br /> Job Address _ �.,f.t.. f�. �� �� City Lot Site/Acreage <br /> Owner's Name QnAl - UA U G d/.y- Address Phone ` 63!J j2 <br /> e� <br /> ContractoriJy %..Aw Address License No. M Phone <br /> TYPE OF WELL/PUMP: NEW WELL .0 4 WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well C7 <br /> PUMP INSTALLATION ❑ ; " SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> DISTANCE TOWEAREST: SEPTIC TANK SEWER LINES :DISPOSAL-FLD.I .PROP. LINE <br /> FOUNDATION AGRICULTURE WELL # OTHER WELL PiTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications <br /> M Pubiic i'l Other ! ❑ Delta Depth of Grout Seal Type of Grout <br /> M Iffioation ,_,_.Approxi Depth ❑ Eastern r . Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Welt Diameter Sealing Material & Depth <br /> Depih ' e, Piller Material & Depth' <br /> TYPE OF.SEPTiC WORK; NEW�INSTALLATION AEP /AOQITION,0 DESTRUCTION (No septic system permitted if public sewer is <br /> '55*)a1Z H(7,0 u F" , ' f �-- � � t available within 200 feet) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: __Q_ Number of bedrooms © ( L ���D <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mig 4- �~Ca acit <br /> f> Y" No. Compartments <br /> PKG. TREATMENT PLT. ❑ f� i # Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Irl No. & Length of lines # t Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation i Property Line <br /> SEEPAGE PITS 11 Depth Site ' Number <br /> SUMPS Ll 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 a <br /> Home 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 subject to workmen's compensation laws of California." Contractor's hiring or subcontracting 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 C ' nlo." <br /> The applica mu call I a required ' spgctions. Complete drawing Pan reverse side.._ <br /> Signed Title: Date: <br /> OR EPAATMENT USE ONLY <br /> Application Accepted by CA.6 Date C Area <br /> Pit or Grout Inspection by ` Date Final Inspection by Date f 0 <br /> ,Additional Comments; <br /> Applicant - Return all capias to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ©V\ <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ^ <br /> INFO CLASH �{� Q <br /> . EH 17.2 IIIEY.1/454 <br /> �. t �� l�+ i 1D at <br /> EH;i•:e �O� 6 <br />