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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <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 San Joaquin County Ordinance No. 549 end 1862 and the Rules and Regulations of San <br /> j� Joaquin County Public ryHealth Services. i <br /> ►\Job Address ` Lam+ Cit Gr'' Lot Sit: Acreag <br /> -74 Owl <br /> Owner's Na <br /> " Address ZP,1)2 /L��Ufl,0 Q� �Phoney, <br /> K-Contractor � Address License No. ""-- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Ne11 ❑ <br /> 4 PUMP INSTALLATION 0 SYSTEM REPAIR OTHER p Monitoring trail <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER L NES # /DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICUL RE WELL OTHER PITS/SUMPS -; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ONSTR TION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom i 0.Manteca a.-of ell Excavation Dia. of Well Casing . <br /> U Domestic/Private O Gravel Pack t 0.Tracy T of Casing Specifications <br /> La Public 1-1 Other 0'Delta hof Grout Seal Type of Grout <br /> M Irritation Approx, Depth 01 Eastern Surf a Seal Installed by <br /> Repair Work Done U Type of Pump <br /> H.P., State Work Done_ f <br /> Will Destruction ❑ Well Diameter I ing Mater i Depth ± <br /> Depth 111er ilatertal fl Depth h <br /> i Oti: <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION GI (No septic system permitted if public sewer is t <br /> available within 200 feet.) <br /> Installation will serve: •Residence X •Commercial—-'Other <br /> Number of living units: ., Number of bedrooms ^ Il t <br /> Character of soil to a depth of 3 feet: S/41yad y _ y L 001A" Water table depth Azo <br /> SEPTIC TANK Type/Mfg , QP/C��� ., Capacity 1 No. Compartments <br /> PKG:TREATMENT.PLT.Cl r, "�, Method of Disposal t <br /> Distance to nearest: Well. Foundation / Property Line -4f.17— <br /> LEACHING <br /> LEACHING LINE 114 No. S Length of lines _,.L.. ' � '� Tor I length/size 3 <br /> FILTER BED n Distance to nearest: Well,ZRS /Foundation Property Line <br /> SEEPAGE PITS l I Depth Sixes"� �r�� - Numbers '{ <br /> SUMPS Ll Distance to nearest: /Weli,IZO 4 Foundation Property Line,�,ro i <br /> DISPOSAL PONDS O <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, ands+ <br /> rules and regulations of the San Joaquin County f� <br /> Hpme owner or licensed agent's aignatura certifies-the following: "I certify that in the performance of the work for which this permit is issued. I shall not- r I <br /> employ any person in such manner as to''becoma subiect to workman's compensetion.la`ws of California.-"Contractor's hiring or sub-contracting signature; <br /> certifies the following; 'Y certify that in the performance of the work for which this par 044+'!," shell Oft O. ns s to workman's compensa•". <br /> tion la California." " `► ` ^�� ``,, <br /> ;y ? <br /> .a t .. i . <br /> The ap Iican must call for ulred nspections. a lata drawing on re aria; ide. <br /> Signed Title: fir`+y - Date: /40 <br /> . 14 <br /> 7:�!��RTMENr"WSE�� ONLYApplication Accepted by Date Area <br /> { <br /> ��� i } <br /> Pit or Grout Inspection by ! Date i�sl in pectior by Data !� <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HE `SPH SERVICE$' — <br /> ENVIRONMENTAL HEALTH DIVISI ERitIT/SERYICES k:'i' <br /> 445 N SAN JOAQUIN, P 0 BOX: 0, STOCKTON, CA?9 201 <br /> Imi­ <br /> EEE AMOUNT DUE A UNT REMITTED CASH RECEIVED BY DATE PERMIT'N0, ` <br /> . rH,a.l,ri�lCr, 10 8 <br />