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APPLICATION FOR PERMIT <br /> SAN JOAQU3IN COUNTY PC]13LIC HEALTH SERVICES' � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009,, STOCSTON, CA 95201 p <br /> (209) 468-3447 <br /> RTMIT 9MIRES 1_YEAR ?R-01t PATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,ta San Joaquin County for 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. ,g <br /> Job Address � f � [ � City C&Azaw AILt Size/Acreage <br /> Owner's Name Address f P Phone <br /> Contractor Address +�' �" � - �' License No. ���� <br /> ��Phone <br /> TYPE OF WELL/PUMPJ NEW WEL '" WELL REPI`XCEMENT-C]------DESTRUCTiON-B-out-of"Service-Nell---D�-- <br /> PUMP INSTA ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> LLATlO C7 �z <br /> DISTANCE TO NEAREST:"-SEPTIC TANK Ifo_0 r SEWER LINES _ 1-" DISPOSAL,FLD.IMcT` PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUM <br /> PSb' ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS <br /> f] Industrial pan Bottom ❑ Manteca Dia. of Well Excavation 9 Dia, of Well Casing <br /> <omestic/•Private�� O--Gravel-Pack - ,Tracy , -Typo-of Casing _Specifications_—s <br /> M Public Cf Other ❑ Delta Depth of Grout Seal T pe of Grout # <br /> Q Irrigalion Approx, Depth b Eastern Surface Seal installed by <br /> r: <br /> Repair Work Done 0 Type of Pum H.P. ork_Done_�' f-° •c' _ __-_ <br /> Well Destruction O W meter Sealing Materia. <br /> Depth Filler MWArn,aiAepth„'.� --- <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAfR/ADDITION L-f DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 f ) <br /> 4 eet <br /> Installation will serve: Residence Commercial— Other. <br /> Number of living units: Number_of bedrooms 1. <br /> Character of soil to a depth of 3 feet: / 1=: _ "�Water table depth <br /> SEPTIC TANK ❑ Type/Mfg f r Capacity�F'3% i NO. Comp r <br /> PKG. TREATMENT PLT, ❑ _Irl' .►---Method of Disposal <br /> r t 14”r <br /> Distance to nearest: ell b t Foundation ' .Property Line, <br /> F LEACHING LINE L=hNo.-&Lergt l�lines _ Tota_I,.lengih'/si:e ��• _ ' <br /> FILTER BED ❑ Disianc oTrBarest:; Wall Foundation Properly Line'- <br /> SEEPAGE PETS /, Do,th Size Number <br /> SUMPS tance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby.comify 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 fegulations of the San Joaquin County <br /> Homo 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 shell not r` <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 shall employ persons subject to workman's compensa- <br /> tion laws of Californ <br /> f <br /> The applicant mus <br /> ire d 'Rspemp eke drawing on rev mid <br /> Signedy �'�� �Title: - / <br /> Date: <br /> �FDEPARTIMENT USE ONLY <br /> Application Accepted b r ` r <br /> P Y Date Area. � i � � � r <br /> Pit orr0 Inspection by { ate1 Y-�9/ Final Inspection b Date <br /> t <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - g <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES -! <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMr7'NO. <br /> G <br /> Cf <br /> (p �^7 a <br /> . EHk3-2�IREV.iinS! L��f t^�'( tl_ f <br /> Eli;4aj ( tE <br />