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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> PAYMENT <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 N a 3 V 2 3 1992 <br /> SAN JOAQUIN COUNTY <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P,JBL;C HEAi_TH SERVICES <br /> (Complete in Triplicate) [fNiRONMENTRLHEAL-rH, DiViS;Cp" <br /> Application is hereby.aade.to Sen Joaquin County for a permit to construct and/or install the Work herein described. This <br /> application is made in ccopliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.3 b QCity Lot Size/Acreage <br /> E-C+fi" qz3� <br /> Owner's Name Address 00 Phone <br /> +1 <br /> { E_ 1 � 1 <br /> Contractor lr Address11AI^ License No. —Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well .❑ <br /> _PUMP INSTALLATION O .SYSTEM'REPAIR OTHER ❑ Monitoring Well ❑ <br /> '— <br /> !,.DISTANCE-TO NEAREST:`SEPTIC TANK '� SEWER LINES � DISPOSAL FLD. - .PROP. LINE ' <br /> FOUNDATION AGRICULTURE NVEII '� ' OTHER WELL--- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL ~PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> `0 industrial ❑ Open Bottom, ❑ Manteca'Dia. of Well Excavation Dia. of Well Casing <br /> bQ Domestic/Private Cl Gravel Pack/,✓❑ Tracy„_4,%.:�Type of Casing_. Specifications <br /> f'1 Public 1. <br /> fl Other-xn Delta Depth of Grout Seal Type of Grout <br /> 13 Irritla" , . -Approx'Dspth i I I Eastern Surface Seal Installed by <br /> Repair Work D:;,4 U Ty of Pump H.P, f ' _ State Work Done <br /> Well Destruction '.p*/Well Diameter Sealing Material'11i Depth <br /> Depth filler Material i Depth <br /> TYPE OF SEPTIC WO K; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I t INo septic system permitted it public sewer is <br /> •`.tom .r—�; available within 200 few.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms F' <br /> Character of sotl to a depth of 3 feet:.:, Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT FLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L'1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> k <br /> SEEPAGE PITS I I Depth Size Number <br /> _SUMPS_ fL] Distance to nearest!_ .,Well- F_ounaation - -Property_Line,—­ <br /> DISPOSAL <br /> ine, - <br /> DISPOSAL PONDS ❑ } f <br /> I hereby certify that I have prepared this'i 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 I <br /> Homs owner or licensed agent's signature certifies the following: "I cartify that in the performance of the work for which this'permit is issued, I shell not <br /> employ any per in such manner as to;bacome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the f i :,1 certify thinin the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws `T , <br /> ...__Thipplic- _ t call for all r' red iris 'ons. Complete drawing on reverse side. ; <br /> Signed Title: pate:: <br /> *a, r FOR DJEPAFITMEWUSE ONLY j <br /> Application Accepted by Date h IArea / <br /> Ph or Groti inspection b # Date Final <br /> pec y Inspection by Date <br /> Additional Comments: f <br /> i <br /> Applicant - Return all copies to: San Joaquin County 'Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 <br /> FEE INFO A OUNT OVE AMOUNT REWTTEp K ECEI D BY ATE PERMIT"NO, <br /> s <br /> a EH 1111(REV.r/I451 0 " 44�v <br /> i <br /> EH 11-Z6 <br />