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w +7�� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL `HEALTH DIVISION <br /> P O BOX 2009'r' 3TOCSTON, CA 95201 <br /> (209) 468-3447 <br /> PEMIT EMIREB 1 YEAR FROM .PATE ISSuE <br /> (Complete in Triplicate) <br /> Application In 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. <br /> -LO <br /> Job Address K 1 Cit Lot Size/Acreage. <br /> ' • ` <br /> Owner's NamAiL Address Phone <br /> 1.1 Wt. . L ��Addrgss: License No. >t",e Is <br /> • Contractor _ <br /> TYPE OF WELL/PUMP: - NEW WELL-0 ❑ DESTRUCTION 0 Out of Service Well Gl <br /> PUMP INSTALLATION Wr`00� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 } <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 /> 0 Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. o1 Well Casing <br /> O Domestic/Privatr ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Py61ic CI Other O Delta Depth of Grout Seal Type of Grout <br /> lrnpation ,_,.,.Approx. Depth L415.sStern Surface Seal Installed by � <br /> Repair Work Dodi f fET Type of Pump �. i _ H.P. t State Work Done e <br /> Wall Destruction,. O Well Diameter Sealing Material i Depth 1 <br /> DepthFiller Material'& Depth , <br /> TYPE: OF SEPTIC:WORK:';NEW INSTALLATION❑ REPAIRIADDITION M DESTRUCTION CJ INo septic system permitted if public sewer,is <br /> available within 200 feet.) <br /> Installation willserve:fResidence_ Commercial___ {Other <br /> Number of living units~�j Number of bedrooms <br /> Character of *aIf•tb e,depth of 3 feet: c <<F Water table depth + ` <br /> SEPTIC TANK`' ❑ Type/Mfg �Cepacity No. Compartments I <br /> PKG. TREATMENT.PLT. Cl <br /> ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line. <br /> LEACHING LINE C1 No. 6 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPSCI Distance to nearest: Well Foundation Property Line P9 <br /> DISPOSAL PONDS `. ❑ 3 <br /> 1 hereby certify that I tieve prepared Phis 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 lican 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 n in suc nner as to be ome Su ' t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies th oltowing: "I ce it hot in the rf r nce f the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion low of California." } <br /> The a !'cant mus call If requir ns Is rawing n to side. <br /> Signed k Title: _ " M Date: g �"- Z c 1 I f <br /> ENT USE ONLY k <br /> Application Accepted by ` &AA.- Date2 — Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> aL ` `I <br /> y <br /> Additional Commenter , _ 4 <br /> a Applicant - Return all copies to: nSAN JOXQUIN. COUNTY PUBLIC HRALTN SERVICES <br /> ENVIRONMENTAL-HEALTH DIVISION PkRMIT/SERVICES <br /> 445 N SAN JOAQUIN, 0"0"130X.2008_; BTOCSTON; CA 95201FEE <br /> 1" <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY• ~ _DATE PERM17 NO, <br /> . EH 13-26 74 TREY.lIKsl O02�. <br /> EH:x• -23 r •' F 0%1% <br /> i <br /> n <br />