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T APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1Z> P, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, _PHONE (209)468-3420 rj-��--9 2--- ' <br /> P 0 BOX 2009, STOCKTON, CA 95201 r <br /> PERM T E%PIRES 1 YE FR M DATEISSUED ' <br /> ., <br /> (Comp_lete in Triplicate) I <br /> .w <br /> Application is hereby tsade:to San Joaquin County for;a�Permi0to 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 /> Josquin County Public Health Servicee. <br /> Job Address rC City Lot Size/Acreage <br />` Owner's Name Address Phone <br /> Contractor 141AUSK �.I�1//f reel S Zr4t�vo,-V Phone 9 —2v' f <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMEN DESTRUCTIONUK t of Service well ❑ ; <br /> PUMP INSTALLATION-El SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDI�PROP. LINE <br /> FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL"v*4 PROBLEM AREA CONSTRUCTION SPECIFICA IONS <br /> t <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc vation Dia. of Wall Casing <br /> t".omestic/Private CaGravel Pack ❑ Tracy Type of Casing -Specifications SL& L2 ' <br /> I'l Public Cl 0 her D I De th f=Grout Seal t <br /> f f�� P Type o! Grau { <br /> I I Irrigation ppr x. Depth f°i`Eg n Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. J • iSt <br /> WOO Destruction TJ K: Well Diameter Sealing Material i Depth <br /> Depth_2�� — ;Filler Material & Depth ; . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) } <br /> Installation will serve: Residence— Corrimercial Other <br /> Number of living units: Number of bedrooms ` <br /> Character of soil to■depth of 3 fest: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg <br /> PKC. TREATMENT PLT.❑ Capacity No. Compartments ' <br /> Method of Disposal - ! <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED Cl Distance to noarest. Well <br /> Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS U1 Distance to nearest: Well Foundation Property Line �• r <br /> DISPOSAL PONDS 0 ` <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,irate laws, <br /> rules and regulations of the San Joaquin County y <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 10 workman's compensation laws of Csiifornia." 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 C .11 <br /> The appy t s 11 f r all r tions. Complete drawing on rep-9to side. <br /> Signed Title/ <br /> Title: Date: j <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by C Date , # <br /> ea <br /> Pit G t nspaCtio Da;e Final Inspection b Date �21 <br /> Additional Comments. <br /> ,¢p 11 aft® Return all copies to: San Joaquin County Public Health ServiceS,10 <br /> Environmental Heal,th,Permit/Services <br /> s a6a7'— �la�o ' 445 N an J aq in P O t3ox 2909,0 3 n, GA 52D1 <br /> `r �' �E �� may ./c .G coir <br /> FEE `AMOUNT DUE AMOUNT REMITTED CASH <br />!- <br /> CA <br /> , CK RECEIVED 9Y <br /> u <br /> �C DATE PERM!I'NO. �fp� <br />. Ell M24(ntv.fin5) e Z� <br />