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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 2=11 EXPIRES-_1 YEAR FROM DATE„ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby rnade,to Son Joaquin County for a permit to construct and/or install the vork 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 /> Juin County Public Health Services. <br /> Job Address �� �- City Lot Size/Acreage la QCJ'C <br /> Owner's Name e � Address S7cI_J�r1e,1736-C' Cts• Phone <br /> ���tl <br /> ractor <El��! Addre License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Yk.Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER p Monitoring well p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public t. Other 0 Delta Depth of Grout Seal Type of Grout <br /> G Irrigation _.Approx. Depth ❑ Eastern Surface'Soul Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material 4 Depth <br /> Depth Filler material A Depth �} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION!-) REPAIRIADOITION 0 DESTRUCTION CI (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence r Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire 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 <br /> Home owner or licensed agent's signature certifies the following: "E 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 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> TR DEPARTMENT USE ONLY <br /> Application Accepted by Date v 1~11 Area <br /> Pit or Grout Inspection by Date FinaE Insp tion by Deta <br /> Additional Comments: <br /> s <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201 <br /> FEE <br /> INFO AUNT DUE UNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. <br /> a EH 13 24 <br /> -24111EV.!/nSl r{.J l� C) (�� <br /> EH 3 f—7'0 ��f ••� <br />