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1 <br /> APPLICATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES ' l YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby toads to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in convalance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> D tow <br /> Job Address �`�' A City �r`-� Lot Size/Acreage <br /> r / ` <br /> Owner's Name o i'' - dFe )L Phone; <br /> CantractorLN �_+y1A� _ Address � C * License No. m ag Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ 1140nitoring Well ❑ <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 t <br /> L-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private O Gravel Pack C] Tracy Type of Casing_ Specifications ... <br /> I'1 Public Cl Other n Delta *i Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation —Approx. Depth_1-1-Eastern Surf aee Seat installed by � <br /> Repair Work Done U Type of Pump"==" _I-, 'H.P. - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth v� <br /> Depth ' biller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I TRUCTION I I iNo septic system permitted if public sower is <br /> !! __ available within 2(10 feet.)' <br /> Installation will serve: dente 1�.�i:ommercial ther <br /> Number of living units: Number of bedrooms t (, <br /> Character of soil to a depth of 3 feet:-' Water table depth <br /> SEPTIC TANK. a❑ Type/Mfg `` Capacity No. Compartments <br /> PKG. TREATMENT PLT'❑ �/ l Method of Disposal, <br /> +"� <br /> t Distance to nearest: Well Foundation Property Lina lsli_LL <br /> rtp <br /> LEACHING LINE LD­96. 6 Length of lines j�Tots] length/size <br /> Ra <br /> FILTER BED ❑- Distance.to-nearest:-...K.rWell—__I_W_!�-�Foundation Property Line <br /> SEEPAGE PITS I I Depth Size 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 <br /> rules and regulations of the San Joaquin County <br /> Home owner OF licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fallowing: "I ify that in the performance of the work for which this permit is issued,I shall employ persons subjecuto workman's compensa- <br /> tion of Califomla.' <br /> The applicant cal for all r ui plate Ing on reverse aid w y��- <br /> Sig Title: -- Date: -.7' <br /> �9_., <br /> e <br /> �PARZIWEXTUSE ONLY 1 <br /> Application Accepted by - Date -1 ,,�,_ Area n <br /> Pit or Grout Inspection by Date Final Inspection by `' Data <br /> 4 <br /> Additional Comments:: - <br /> Applicant -Return all copies 'to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CASE# RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> r q <br /> . EH 1 -24(REV.r/R S) S �� r OO 114 ,100 �vf]L7�,.-. 1-7 <br /> 4g #_ a <br /> EH t4-as <br />