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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> E (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 /> application is made in coupliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / /YS q <br /> Job Address /0 �'y� - `City ,�- Lot Size/Acreage I <br /> Owner's Nemacous-) - �` d ��Address �` ' Phone 6 7 v <br /> s �Z <br /> Contractor ��'t,-- Address _i 2 License No:3222JS Phone ` 7 <br /> TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT n DESTRUCTIONXOut of Service well ❑ <br /> PUMP INSTALLATION' _ SYSTEM REPAIR 0 OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _2-C-1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom O Manteca Dia, of Well Excavation f Dia. of Well Casing <br /> Domestic/Privates Gravel Pack 0,Trac � <br /> y- - - Type of-Casing--- Specifications �` y <br /> M Pubtic C1`Other 0 Delia'j Depth of Grout Seal 1,9. Type of Grout Ccn,t�T <br /> CI Irriontlon yJ Approx. Depth ❑ Eastern r''Surfacs Seal Installed by a� <br /> Repair Work Done D T H:, <br /> P.of Pump S� H:P. 1-` __ _ _ State Work <br /> Well Destruction 0 z-Woll Diameter ���_ Sealing <br /> Material i Depth <br /> Depth Za v, Filler;katerial & Depth <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION L_1—REPAIRIADDITION M DESTRUCTION C_LINo septic system permitted if public sews, is <br /> I -available within 200 feet.) <br /> Installation will serve: Residence— Commercial____, Other <br /> Number of living units: Numtier of bedrooms <br /> Character of soil toa depth of 3 feel: f f Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length.of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I' Depth Size _ Number <br /> SUMPS LI. Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> I hereby certify that I have prepaved this application and that the work will be done in'iccordancs with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Horne 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 or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shad employ persons subject to workman's compensa- <br /> tion laws of California:' <br /> The applicant must ca for a I requir d inspections, Complete drawing on reverse side. <br /> Signed Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> ..Pit or Grout Inspection by Date Final Inspection by /DGrto r <br /> Additional Comments: 'r' t! <br /> Applicant - Return all copies to:' SAj{JOAQUIN COUNTY PUBLIC HBALTH SERVICES <br /> ENVIRONMENTAL 111ALTH DIVISION PERMIT/SERVICES' <br /> 445 N SAN JOAQUIN,,P 0 BOX 2009, STOCKTON, CA 95201 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. <br /> . E14.7{IREV, <br /> iir6l <br /> f EKK;beelIg <br /> 4 <br />