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4W. <br /> APPLICATION FOR PERMIT <br /> Q <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> tom.�✓►- Pe- ,t e-*,- <br /> (209) 468-3447 � <br /> R ?R.0A_LI)_ATR_ ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby msde 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 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Q <br /> e .. Lot Size/Acre e <br /> Jab Address- City, aFS <br /> Owner's Name FDn 91 IC42 Address/ {; W,,:2 <br /> one <br /> Contractor L Address /,� r License No ,42<M Phone� � <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well GI <br /> PUMP INSTALLATION 0 SYSTEM REPAIR Ir OTHER ❑ Monitoring Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f-'1 Industrial Ea Open Bottom © Manteca Dia, of Well Excavation Dia. of Well Casing <br /> $4 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> 0 Public Cl Other p Delta Depth of Grout Seal Type of Grout <br /> Cl Irrigation ._.ApproK, Depth © Eastern Surface Seal Installed by <br /> Repair Work pone Type-of Pump ,,¢ y H.P. f t. State Work Done <br /> Well Destruction I Well Diameter Sealing Asterial i Depth <br /> Depth Filler Material_i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION M DESTRUCTION 0 lNo septic system permitted if public sewer is <br /> t, <br /> available within 200 feet.! �, <br /> Installation will serve: -Residence_ Commercial Other <br /> Number of living units: Number of bedrooms 5 <br /> Character of$oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK �'� 0 Type/Mfg (Capacity No. Compartments <br /> PKG. TREATMENT PIT:_. Cl ;h Method of Disposal <br /> Distance to nearest: Well Foundation. Property Line <br /> LEACHING LINE {, 0 No. & Length of lines r� r' Total length/size <br /> FILTER BED 171 Distance to nearest: Well - Foundation Property Line <br /> s { i <br /> SEEPAGE PITS It Depth Site ` ' Number <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 laws, and F <br /> rules and regulations of the San Joaquin County <br /> 117, <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 t <br /> employ any person in such manner as to become subject to workmen'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 shall employ persons subject to workman' compensa• <br /> tion laws of California." <br /> The ap �mucall orall required ' cetio Co fete drawing on r side: y <br /> �q,8!flJp � <br /> .Signed Title: ,(� J�� / Date:ILK <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Q�ibb� _ Ufa, Date L Area <br /> Pit or Grout Inspection by Data - __ __ Final Inspection by ���" T Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC"HEALTH.SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA D5201 <br /> INEE OUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> 1 <br /> r EH 13.24 IREV. Si <br /> EH 1.4.2 t Ora <br /> 1 <br />