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AP$L I CAS I ON FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> REMIT- EMIRM 1 YEAR FROId DATE ,ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I <br /> Job Address / _dc City Lot Size/Acreage <br /> Owner's Name Address / _AW tV 7/ Phone <br /> O <br /> • Contractor � �� ddress � License No.� n// Phone � <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR OTHER O Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLD. PROP. LINE c-cam <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .._ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _2s ; <br /> n Industrial 0 Open Bottom ❑ Manteca Oia, of Well Excavation Dia. of Well Casing <br /> L) Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public I-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Irrigation •w.Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done D Type of Pump T H.P. State Work Done 451 <br /> T�iE'.Blw►lFj �` <br /> Well Destruction O Well Diameter Id Sealing Material 4 Depth iV1FZL2:> .4.04f &A <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW"INSTALLATION D REPAIR/ADDITION M DESTRUCTION GI (No septic system permitted if public sewer is <br /> �c available within 200 leel.l poax-_ f �© <br /> Installation will serve: Residence— Commercial— Other y�,rCLt7 h <br /> 1_ 1AJ <br /> Number of living units: Number of bedrooms � �y�,� O�JD IT—, <br /> Character of$oil to a depth of 3 feet: eL_&_��W�a " b <br /> pth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line a� <br /> LEACHING LINE ❑ No. & Length of lines Total length/size y <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS ( I Depth Size Number i <br /> SUMPS LI Distance to nearestr Well Foundation Property Lina <br /> DISPOSAL PONDS 0 <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 S <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the followin ? <br /> a g g. "I certify that in the performance of the work for which this permit Is issued, I shall net <br /> 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t Or uiredtn""� Complete drawing on reverse side. <br /> Signed a e: Dale: / l <br /> 3 <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date l <br /> Additional Comments: _ <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES I <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FE4 <br /> INFO AMOUNT DUE AMOUNT Rt?MITTED CACKS <br /> SH RECEIVED BY DATE PERMIT'NO. <br /> + EH Ili.24IREV.rn$r V/,07/ <br /> q �y <br />