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"rr. <br /> 'M APPLICATION FOR PERI[I T <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 /> .I <br /> !PERMIT E%PIRES 1 YEAR FROM DATE ISSUND <br /> (Complete in Triplicate) <br /> Application is hereby made to Sea Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in cosspliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Servicee. � <br /> i. <br /> Job AddressA15City f,ot Size/Acreage <br /> Phone <br /> nzz <br /> is Name <br /> ass `�� r <br /> "Lg!�Corn r A° ss 'CTcense No. Phon <br /> TYPE OF WEL.LIPUMP: NEVV'W/E 00 '__--_"WELL REPLACEMENT'Cl"""""--DESTRUCT1ON-L9-Out-of-Service Nell,­D <br /> ' - PUMP INSTALLATIOf+P SYSTEM REPAIR D OTHER O Montoiring tifell-,,tin <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE * > <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDERS USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ dustriel El Open Bottom 0 Manteca Die. of Well Excavation Dia. of Well Casing <br /> omasticlP�ivate ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> 1 Public El Other �� n Datta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ Approx. Dept I Eastern Surface Seal Installed by <br /> Repair Work done ❑ Type of Pump H.PState Work Do <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> J Depth it Filler Material to Depth _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i ]-DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> .-.--. ,available within 200 feet.) <br /> Installation will serve: Residence_i Commercial— Other <br /> Number of hying units: Number of bedrooms <br /> Charecter of,soll to a depth-of$feet: Water table depth <br /> ".7 <br /> SEPTIC TANKS 0 Type/Mfg s Capacity No. Compartments r <br /> PKG. TREATMENT PLT. ❑ ? .11. r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER PIED � 0 .Distanc@_Io_n@arest._____.Weil Foundation Property Line <br /> i I I <br /> SEEPAGE PITS 11 Depth 4, Size Number <br /> i <br /> SUMPS LI Distance-to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> I hereby cerlify�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 of licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shell 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 persons subject to workman's compensa- <br /> tion Iaws of C file." <br /> The appllc "+.I t call f 'rod in pop ions. Complete drawing on r arse side. <br /> signalTitl Data: <br /> F DEPARTMENT use ONI. <br /> � II q t <br /> Application Aceaptad by 11 Dats `^� ^�Z-- Area 2 1 Z <br /> Pit or Grout'lnspection by Date Final Inspection by�� ��.rr'�� Date t� � <br /> k Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> y, p 445 N San Joaquin, P 0 Box-2009, Stkn, CA 95201 <br /> :i <br /> FEE AMOUNT DUE:ll AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br /> INFO r I (CASH Q <br /> « EH 17.74{t1EV.1/>1 5! <br /> EH 14-26ze r r 11 !a r� e) 1�'�•5 ��' Q t a~ <br /> 4 <br />