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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> :S <br /> PERMIT EXPIRES 1. YEAR FROM DATE S <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 i <br /> 1 1. - Lot Size/Acreage <br /> Job Address J 3 J"r ` O !1 '^-' CityZ4yt' <br /> Owner's Name <br /> 5; We Address <br /> _ Phone 6 ' t? Tc <br /> Contractors <br /> Address a License No. Phone <br /> service Rell <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of <br /> Well C7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGMCULTURE WELL OTHER WELL PITSlSUMPS — <br /> INTENDED USE TYPE OF WELL PROSLEM-AREA- CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Fl Domestic/Private ❑ Gravel Pack n Tracy Type of Casing_ Specifications <br /> I'1 Public k 1-1 Other C1 Delta Depth of Grout Seal Type of Grout <br /> y � - <br /> i { Irrigation _Approx. Depth .'t I Eastern Surface Seal Installed by <br /> H.P. -�--^•,--- <br /> Repair Work Done U Type of Pump r State Work Done _ <br /> sealing Material i Depth`= ' <br /> Well Destruction ❑ Well Diameter <br /> t Filler Materia14 Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDlTION iDESTRUCTION I I,1 N septic system permitted i( public sewer is <br /> available within 200 feet.) <br /> i <br /> Installation will Terve: Residence Commercial— Other <br /> Number of living units: ...,c._ ,Number of bedrooms_2— i { <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. D Type/Mfg k3 + Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest:.. Well Foundation Property line <br /> El <br /> LEACHING LINE LW No. A Length of lines 0 Total length/size <br /> Well. O Foundation Y 0 Property Line '- <br /> FILTER SED ❑ Distance to nearest: ,�-- j <br /> 1 "y'A <br /> �.,�.� e <br /> SEEPAGE PITS Depth . � ---Size Number <br /> SUMPS LI Distance to nearest: wellC�' Foundation g Q - Property Line <br /> DISPOSAL PONDS ❑ j <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county or state laws, and <br /> rules and iegulations of the San Joaquin County` '- <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, 1 shall not <br /> employ any person in such manner as to become subject t6 workman's compensation laws of California." Contractor's hiring or'sub-contracting signature <br /> cartifin the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject.to workman's compensa- <br /> tion laws of California. <br /> The applicant st call for awmAukwredl ' s ct' ns. Complete drawing,o'n reverse si . <br /> Signed ^- Title:.i' Date: <br /> FOR EPARTMENT USE ONLY <br /> ^ •�- +Z Z Area�/ "r �. <br /> Application Accepted by Dat <br /> Pit or Grout Inspection by date final Inspection by Date 1 /x� <br /> � •t 3 <br /> Addgbnil-Comments: <br /> r Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> __.,r.,...,,,,._445_N-.San,.Joaquin, P-0`Sox 2009;"Stkfi', CA'95201^^A"`'" <br /> FEE AMOUNT DtJE °L _ Ol1kT REMIT1t D SH" RECEIVED BY DA TE PERMiT'NO. <br /> INFO //JJ <br /> . EM M21 tllEv.I/its <br /> 11 T ,[7_( <br /> I EH 1629 (J �/ <br />