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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION P4 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ocr o <br /> SAIV Joao 3 i93 <br /> PERM T EXPIRES YEAR FROM DATE �C, ` Ul ! 2 <br /> (Complete in Triplicate) Q�i� � �F�II rfl,44) <br /> �1Ty <br /> Application is h reby made to Ban Joaquin County for a permit to construct and/or install the work heciiieaci�3"& i. This <br /> application is a in ccWliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regia San <br /> Joaquin County blic Health Services. <br /> t <br /> Job Address 3 I` City Lot Size/Acreage <br /> Owner's Name Address - Phone <br /> Contractor 0 <br /> ` Address License No. atOs��i Phone V <br /> TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT 171DESTRUCTION ❑ Out of Service Well <br /> is PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring hell .C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 1. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE, TYPE OF WELL OF66 U9 AREA''CONSTRUCTION SPECIFI A I <br /> C1 I dustrial 0 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing j <br /> WomesticlPrivate€ D Graved Pack ❑ Tracy Type of Casing Specifications <br /> i-1-Patrtic— �-��-1-ONrer" ---=,T:.olta�i�..^eptlyof-Gcout_Seal_ -" —TYpe_of,Grout <br /> I I Irrigation —.Approx. Dep <br /> th 11/1 Eastern S dace Seat Installed by ` 1 <br /> Repair Work Done L7 Type of Pump `r" H.P. ___ State Work Oone \V? <br /> Sealing Material i Depth <br /> Wen Destruction ❑ Wall Diameter - r <br /> 1papth' { tiller Natiiial i Depth t <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1-1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> 4 <br /> Installation will serve: Residence— -Commercial'— Other. <br /> Number of hiving units. •Number_of bedrooms N s <br /> lix <br /> Chatactm of soli to a depth of 3 feet. Water table depth, <br /> SEPTIC TANK. i---0 3 Type/Mfp :Capacity _ No. Compar�manls <br /> PKG. TREATMENT PLT.Ll '; a E:t Method of Disposal <br /> r Distance to nearest!"�-Y Well Foundation Property Line <br /> LEACHING LINE C1 ; No. b LengtH of tines f ' Total length/size <br /> FILTER BED # ❑ Distance to nsa' s 'Well "� Foundation Property"Line <br /> I. <br /> 1 h. <br /> SEEPAGE PITS t l'I Depth "r Size, Number <br /> SUMPS sLI Distance`to rteanst: Well Foundation Property Line 4 <br /> DISPOSAL PONDS ❑ .. f T >. `° <br /> I hereby certify that 1•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 Cc6tty ,- <br /> Home owner or licensed ag*nt'i signature certifies the following: "I certlfy 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 bBcome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fo p: ',I certityythat in the performance of the Work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws nis." r f <br /> -A The appl ant st Cslt for all r u'ad inspsat n ."Completerdrewing <br /> Signed Title. Date: {p }G1 <br /> a j R DEP M NLY <br /> Application Acceptsd;by Data -,e,X6 <br /> 'Pit or Grout Inspection by Date Final Inspection by Date �LJ7� <br /> Additional Comments. w�� <br /> f Applicant - Return all copies to: San Joaquin County Public Health Services r,.t• <br /> i Environmental Health Permit/Services V'�w <br /> 445 N San Joaquin, P O Box 2008, Stkn, CA 95201 <br /> FEE AMOUNT DUE A UNT tMITTED -rCK It RECEIVED BY D E PERMIT'NO. <br /> INFO 7. <br /> . EM 1i74(REV, i n 6r ,� ' <br /> EH 14.38 <br />