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APPLICATION FOR PERMIT .. � <br /> .3 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> - P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT- EXPIRES-1 YEAR FROM DATE S I <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 t <br /> application is made in co4liance frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / <br /> Job Address2:4 - City Lot Size/Acreage t 0 t <br /> Owner's Name - Address AMM/61 <br /> [ � �o/� Phone /77 <br /> Contractor <br /> ddress License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTIPCDESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION Q SYSTEM REPAIR C7 OTHE C] Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 7V 'SEIMER-LINES. ""—""��' DISPOSAL FLD. PROP. LINE d , <br /> FOUNDATION QAGRICULTUAE-WEL:ff7r -OTHER-WEL-t�2_.=-PITS/.SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Xbomestic/Private kdravef Pack ❑ Tracy Type of Casing__ -- Specifications <br /> ['I Public 1--1 Other f"! Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation y T^42 <br /> ,U Apprax. Oepth I I Eastern Sr ace Seai In b � <br /> Repair Work Done U Type of Pump. '� H.P. -A1_P State Work Done <br /> Well Destruction X Well Diameter Sealink Material i Depth v <br /> Depth t mlJ_t-• filler Material 4 Depth _ ��a # U4--._ap�l� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> availabie within 200 feet.) <br /> Installation will serve: Residence— Commercial! Other <br /> Number of living units: Number of bedrooms l <br /> Character of toil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity. -' ' '~No. Compartments <br /> PKG. TREATMENT PLT.Cl -. Method of Disposal <br /> 0 tannce to.nearest: well Foundation Property Line <br /> � t <br /> LEACHING LINE C] No. 6 Length of linea Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> • r 4 <br /> SEEPAGE PITS­ 'I I 'Depth Size Number <br /> SUMPS L1 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 /> I rules and regulations•of.the San Joaquin County _ y' / `s: <br /> Home owner or kensed agent's signature candies the following:_"I certify that in the performance of the'wcrk^for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws oYCaiifornia."Contiactor'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 empl6y•persons subject to workman's compensa- <br /> tion laws of California." <br /> x <br /> The applicant r t aI� _uired omplete drawing oil reverie'side. <br /> )�Oh� <br /> Sig1ed X ` . -Date: <br /> sOff RTMEfVT USE-0NL <br /> 1A rea <br /> Application Accepted by � <br /> I Pit or,Gr¢ut Inspection by /r Date -r 3k. Final Inspection by Date <br /> Applicant - Return all copies to: San Joaquin County Public Health ervl'ce'bll"� <br /> Environmental-Heal`t_h Permit/Sertiices <br /> 445-H -San Joaquin; -P o-la x 2009, Stkn,CA-95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY + DATE PERMI7'NO. <br /> INUP CASH <br /> EH 14-M <br /> i . EHt>-titAEv.tie4i ���'' -'f3Y'�r�• 3 f <br /> r. [ �/ 7P ' <br />