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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM DATE ,ISSUED <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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. / 1 <br /> .� �f �IiCJ�� � Y L��16'Lot Size/Acreage �- <br /> Job Address Cit (� <br /> f✓ G as C JE / <br /> PhoneOwner's Name <br /> Conlractor C"SG`l?-Q Sr e s s 7.lfLSIL >��(SAl ALE License I y GJp � <br /> , , No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL [D WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public f-1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by OO <br /> Repair Work Done U Type of Pump H.P. State Work Done — <br /> Welt Destruction © Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of edrooms A:�. <br /> Character of $oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg C f .; Capacity -L No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 j Method of Disposal <br /> Distance to nearest: Well Foundation L r Property Line <br /> LEACHING LINE No. b Length of lines __ c� _ Tolel length/size ",41r2 6 f <br /> FILTER BED Distance to nearest: Well Foundation �_ Property Line ^ <br /> SEEPAGE PITS Depth �y Size i Number <br /> SUMPS Ll Distance to nearest: Well l/SY7 Foundation C7 Property Line ZO <br /> DISPOSAL PONDS Cl <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 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any poison in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cortifios the following: "I certify that in the performance of the worst for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for all required in ctions, Complete drawing on reverse side. <br /> Signed Title: Dole: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date ea <br /> Plt Grout Inspection Do _4� Final Inspection b Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> d- 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> FEE INF*11)-1 <br /> AMOUNT DUE AMOUNT REMITTED C K RECEIVED 8y DATE PERMIT N0. <br /> EM 114.281tV.r,r,bi f� �1Go qD-30I <br />