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APPLICATION FOR PERMIT Q L <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONG',(U PI ' <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 22 MIT .EXPIRES. 1 TEAR ERQKDATE 1115UED <br /> (Complete in Triplicate) <br /> Application is hereby made 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. _P <br /> Job Address ? (�'1 City Lot Size/Acreage 7,54166) <br /> F <br /> Owner's Name qter14a2— ddress 5aAC--Z - Phone <br /> Contractor ` D ddress `' Nr dt- CJ£ icenseNo. v?� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ci Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ 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 /> 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation <br /> Dia. of Well casing <br /> U Domestic/Private L1 Gravel Pack C7 Tracy Type of Casing Specifications — <br /> L't Public -1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> CI Irrigation Approx, Depth ❑ Eastern Surface Sedl Installed by <br /> Repair Work Done U Type of Pump., H.P..- - ---- .State Work Done <br /> Welt Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Li REPAIR/ADDITION Cl DESTRUCTION (No septic system permitted if public sewer is J <br /> available within 200 feet.) <br /> Installation will serve: Residence.L ..Commercial_ Other <br /> Number of living units: Number of be rooms <br /> Character of soil to a depth of 3 feet: n1a 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 -C <br /> LEACHING LINE ❑ No. & Length of dines '~ Z) <br /> FILTER <br /> Total length/size - <br /> FILTER BED n Distance'to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Site Number f <br /> SUMPS LI distance to nearest: Well. Foundation Property Line <br /> DISPOSAL PONDS ❑ .4 _ <br /> I hereby certify that I have prepared this-application and that the work will be done in accordancayvith San Joaquin county ordinances, state <br /> rules and regufations of the San Joaquin County. .r laws, and <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 its Io-6ecdriie subject to wo`rkmen'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 shali employ persons subject to workman's compensa- <br /> tion laws of California," <br /> The applicant m sl call far all required inspections, Ca lata drawing on reverse side; <br /> Signed �� t <br /> Title: Z Date: <br /> FO PART USE ONLY <br /> Application Accepted by ^ 1 <br /> Data � � Area "Z— r <br /> Pk or Grout Inspection by ate _ Final hsps tion by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES I <br /> 445 N SAN JOAQUIN, P 0 B 009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE A1✓OUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO ,{�T H <br /> + EH 13•241REV.iinyr �� U J 12-50-15 <br /> r �'�/H114.26 (.7✓ 9�Ic�io �o- y <br />