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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 / O� 8 <br /> (209) 468-3447 cor!!✓/f' �1vElt,lu�' Su&?�} <br /> oll �� .ZEMIT-11MRSS <br /> 9167 / (Complete in Triplicate) <br /> Application is hereby urade,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coMliance with San Joaquin County Ordinance No. 51+9 and .1862 and the Rules sad Regulations of San <br /> Joaquin Count Public Health Services. N!S 076 3160 --A6) ZOO Z9 <br /> Job Address <br /> �NNI -!.. City Al l Lot Size/Acreage <br /> � — <br /> i —Z <br /> r maw$ /QOG>ff"� Address g Oi�Du hone <br /> Owner's Na <br /> Contractor Address r e 5 License No.�Z_26� Phone <br /> j ce e <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER r5 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL,FLD. � <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL Or*/S! <br /> k Ir <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r fl In 0 Open Bottom 0 Manteca Dia• of Well Excavation /I i±7 C. <br /> U Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing -1 <br /> i[- <br /> I M Public i-1 Other © Delta Depth of Grout Seat os1�`' <br /> CJ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by COt.t <br /> Repair Work Done (J Type of Pump H.P. State Work Done _ c <br /> Well Destruction D Well Diameter <br /> Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> y TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIWADDITION CI DESTRUCTION 0 a�vailabltic system <br /> fpermitted if public sewer is `y <br /> 1 t/" <br /> f Commercial Other <br /> Installation will serve: Residence_.... <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 test: water table depth <br /> t <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments A- <br /> = <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> c LEACHING LINE 0 No. & Length of lines Total length/six. <br /> FILTER BED [_l Distance to nearest: Wall Foundation Property Line <br /> Number <br /> SEEPAGE PITS I I Depth Size r <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 taws, and <br /> rules and regulations of the San Joaquin County <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 to workman's compensation laws of California." Contractor's hiring of 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 compensa- <br /> tion laws of California." I, <br /> The applicant t call for a uired inspections. Complete drawing on reverse side. <br /> 6 89S <br /> Signed Title: Date: - --- <br /> F RDE RTMEN7 USE ONLY �/ <br /> 31 <br /> Application Accepted by Date Area r <br /> Pit or Grout Inspection by Date Final inspection by w Data <br /> Additional Comments: ""`a a4E]lll <br /> Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> i' <br /> FEE AMOUNT DU AMOUNT REMITTEp CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO /✓� �(/�� /y� [�.�$ <br /> . EH 13•141REV.r/n51 C/V <br /> EH 14.19 <br />