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APPLICATION FOR PERMIT <br /> n �y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-5447,34--10 <br /> gEMIT <br /> 68- -7,34-- <br /> iEMIT E%PIRES 1 YfiAR nATR ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address A -T ► 5 h v" Ivnolli City �"'' 4at Sise/Acreage <br /> xOwner's Name �+' Address-GIF * . ` `vim- 'r' w hone r^ ` <br /> nT 1 <br /> KConitactor d -- _—_Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C.7 Industrial O Open Bottom I❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack n Tracy Type of Casing _ Specifications <br /> ❑ Public "'1-1 Other---- �- """ "D OeI'fa— Uepth of�Grout­Seal r *y,. Type of Grout <br /> GI Irrigation �..Apprax, Depth n Eastern L-I 5urfaca Sp lost�llodtb.Y, <br /> wr-� _' H.P. _ State Work Done <br /> Repair Work Done U Type of Pump t <br /> Well Destruction © Well Diameter Sealing Material 8 Depth f <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK':. NEWINSTALLATION J0 REPAIR/ADDITION l7 DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 leet.l <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms.-'- <br /> Chafactef of soil to a�depth o('3 feet: j Water table depth <br /> SEPTIC TANK. ❑ TypMfg Capacity No Compartments <br /> e% <br /> t <br /> PKG. TREATMENT PLT. 0 '° Method of Disposal <br /> Distance to nearest: Well �*' �* Foundation. Property Line <br /> LEACHING LINE 0 No. &`Length'of lines ` Total length/size <br /> FILTER BED C3 DistanceAo nearest: Well �� Foundation Property L-Ine <br /> SEEPAGE PITS 11 Depth �+ Sired=1 t Number <br /> SUMPS LI Distance to neat`st__ Well Foundation *Property Line <br /> DISPOSAL PONDS ❑ *.' r, \ <br /> I hereby certify that I have prepared this applicafioWand That the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I cartify that in the psrtormanca of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject_lo workman's compenaaiion laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following; "I conify that in the performance,o1I'Xhe1work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Ca1ifornla." ! <br /> he applican° s al or all requ 1 mpiete drawing on reverse side. ff Q <br />' igned Ti : 6 Date: <br /> R DEPARTNtENT USE ONLY `` <br /> M <br /> Application Accepted by Data -� Afee <br /> 1, <br /> t JL .d <br /> Pit or Grout Inspection by Date F al Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> i 445 N SAN JOAQUIN, P O BOX 2009; STOCKTON, CA 95201 <br /> KO <br /> FEE AMOUNT DUE AMOUNT AEMIT'TED GASH RECEIVED BY DATE PERMIT NO. <br /> INFO ,�Q"/� [� z <br /> . EH 13.24(REV.irn5) 1�. f '� 3u l <br /> Eht ,x•26 ll OQ ` <br /> i <br />