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srr: <br /> APPLICATION FOR PERMIT <br /> t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR EROM DATE s104M <br /> (Complete in Triplicate) <br /> Application is hereby made.to Saes Joaquin County for a permit to construct and/or Install the work herein described. This <br /> application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. /� <br /> 4 r �I� City F ��/ Lot Size/Acreage Cl PIC I <br /> Job Address <br /> Owner's Name DW6669TaL UVU211711 Address , 2a :ZA6a�C__& - Phone <br /> Contractor <br /> Addressee IVo. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 71 DESTRUCTION 0 Out of Service Well Gl <br /> PUMP iNSTALLA ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well G� <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES � DISPOSAL FLDIPROP. LINE <br /> FOUNDATION AGRICULTURE WELL � OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION S_PECIFICATI NS p <br /> f-1 Industrial 11 Open Bottom C3 Manteca Die. of Well Excavation Dia. of Well Casing <br /> 1�Domestic/Private ZO-Gravel Pack 0 Tracy Type of Casing C- Specifications Xr-,-7K-_ icd <br /> M Public 1.1 then ❑ Delta Depth of Grout Seal Type of Grout,��✓J_4> <br /> CI Irrigation Approx. Depth 0-Easiern Surface Soul Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Walt Destruction D Well Diameter Sealing Material i Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION roil DESTRUCTION CI (No septic system permitted if pubfic sewer is <br /> available within 200 feet.) <br /> Installation yvilt serve: Residence Commercial_:­: Other <br /> Number of living units: Number ol--bedrooms ` <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.C Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines _ Total length/size <br /> FILTER BED C'] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS t I Depth Sire Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> The appli all r all quired inspections. Complete drawing on re seri <br /> Signedor 4,Z OE IF <br /> Title: Date: <br /> 17DEPARTMENT USE ONLY <br /> Application Accepted by L Date 12 �� Area <br /> Pit or Grout Inspection by Dale Final Inspection by Date <br /> Additional Comments: <br /> ApplicaAt - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 <br /> FEE AMOWeqUNT DUE AMOUNT REMITTED CK RECEIVED BY DACE PERMIT'NO. <br /> INFO CASH <br /> EN:1.2e l t <br />