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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �� ,eecelz-IF-) <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 a y-O <br /> (209) 468-3447 <br /> PERMIT EMIRE& I. YEAR PROM PATE ISSUED i972___ <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 mads in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> o�-47-S-S Al, �7Es/�/mss �p City LdD / Lot Size l' crease <br /> Job Address _ -- <br /> Owner's Name Address 6 3-f3 E. e e,9,fA Phone S4 <br /> Contractor_ ALeYl] E. AdogZp Address 7 I.VrA License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring 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 <br /> n Industrial _'©_Open_Bott_om_ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private Ll Gravel Pack 0 Tracy � Type of Casing Specifications <br /> D Public i'1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> G Irrigation _.Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done <br /> Well Destruction O Well.Diameter Seating Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION)I REPAIR/ADDITION M DESTRUCTION M (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> 1 Installation will serve: Residence — Commercial Other fi <br /> Number of living unite: Number of bedrooms <br /> Character of moil to a depth of 3 feet: _ ��/� G 64-4- Water table depth <br /> SEPTIC TANK lOfthType/Mfg ..CC- E^�d Capacity LL2- No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well /a0 Foundation -_�h7 _ Property Line �4 <br /> t LEACHING LINE No. & Length of lines ?' Total length/size /'70 <br /> t FILTER BED F1 Distance to nearest: Well F-6M Foundation f Property Line -.25 47 <br /> SEEPAGE PITS IA Depth _' Size __. � Number <br /> SUMPS Ll Distance to nearest: Weltso. ` Foundation %LG Property Line 30 <br /> DISPOSAL PONDS ❑ <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 or licensed agent's signature certifies the following:"'I cenify 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-IL <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." m <br /> The applicant must call for all required inspections. Compete drawing on reverse side. <br /> Signed X - Titls: . Date: -92? <br /> ° FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> ' 111 f <br /> f <br /> Pit or Grout Inspection by -. t Date Final Inspection by Date D <br /> F 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED_„ fix RECEIVED BY. - DATE PEAM17'NO, <br /> INFO _CA'5H�" "'3 <br /> . EH 13-2401EV.Iiits) t C7� Q� <br /> tiHICH 7�•2a 1 r � i <br />