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APPLICATION FOR PERMIT � <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 /> F <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made-to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> applications in made in compliance vith San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> City G Lot Size/Acreage <br /> Job Address <br /> 7-� <br /> w' G ov r r Phone ��r <br /> Address V'� <br /> Owner's Name E <br /> 7� 30r6 <br /> .+. ��ltrBY/ Phone_ _ <br /> v� - License_No.- _ ----_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT .n DESTRUCTION ❑ Dut ofervice Wel n <br /> PUll MP INSTALLATION IJ SYSTEM REPAIR ❑ OTHER ❑ <br /> s r DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Oia,of Well Casing a <br /> Typwof Casin _ Specifications <br /> C7 Domestic/Private ❑ Gravel Pack ❑Tracy 9- Type of Grout <br /> 11 Public 1:7 Other (� Delta Depth of Grout Seale <br /> w Approx. Depth I I Eastern Surface Seul,lnstrlled by + <br /> I i Irrigation p �y <br /> H.P. State Work Done <br /> Repair Work Done 0 Type of Pump � 1 <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material &%Depth 1" j <br /> 1 <br /> Depth Filler Material & Depth { <br /> --� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION I i INo septic system <br /> m rm tled it public sewer is O j <br /> I <br /> Installation will serve: Residence Commercial Other <br /> Number of Ruing units: i Number of bedrooms <br /> Character of wit to a depth of 3 feat: Water table depth <br /> SEPTIC TANK j� Type/Mfg <br /> d L- Capacity j'S e) No. Compartments <br /> j., , Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well ml Gd Foundation f C Property Line C <br /> E LEACHING LINE 0 No. & Length of lines .�,.�� Total length/size <br /> FILTER BED El Distance to nearest: WeIITj�+ Foundation Property Line <br /> I —' - Number <br /> SEEPAGE PITS I I Depth Size, <br /> SUMPS LI Distance to nearsst: Well Foundation Property Line <br /> s r 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 stgnaturs 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 to workman's compensation laws of California." Contractor'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 employ persons subject to workman's eompenss- <br /> lion laws of California." I <br /> The appZZFOR <br /> at call for all required inspections. Complete drawing on reverse side. <br /> Signec Title: Daae: <br /> i <br /> • DEPARTMENT USE ONLY �46 <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: w /! <br /> Applicant - Return all copies to; San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED �K RECEIVED BY DATE PERMIT'NO. <br /> INFO r ,�\ / 1 rte ) v �j ., <br /> . EH 13-24(MV.1)IM !/4.D V /��'U[� IJ s� `r � Z� %Z 4�-�&5-6 <br /> £H t1•zb <br />