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APPLICATION' FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIIENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, .PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> _=-- PERId T EXPIRES YEAFR M[ DATE S <br /> (Completer in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This, e <br /> application is made in ceropliance.with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> !� YS� Imo_ City Lot '3ize Acre - <br /> Job Address <br /> Owner's Name <br /> Address Phone <br /> i <br /> Contractor FL4 v Address <br /> AE License No._44a �7 Phone ; <br /> Service Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of <br /> Well ❑ ! <br /> PUMP INSTALLATION O SYSTEM'REPAIR ❑ OTHER ❑ <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 /> Cf Industrial ❑ Open Bottom Excavation_ Dia. of Well Casing <br /> n <br /> ❑ Manteca Die. of Well � <br /> •--Type of Casin _..__.� Specifications <br /> n Domestic)Private ❑ Gravel Pack ^'^❑ Tracy y. g- <br /> {'1 Public <br /> 't EI Other Fl Delta Depih of Grout Seat Type of Grout <br /> - <br /> I I irrigation <br /> Approx. Depth i I Eastern Surface Sea] Installed.by <br /> Repair Work Done U Type of Pump H.P. State Work-Dona_ <br /> Sealing Material L Depth" <br /> Well Destruction ❑ Well Diameter <br /> i Depth Filler Material i Depth <br /> F ^ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONX_ I t DESTRUCTION I I INailabpticthin system permitted if public sewer is <br /> Installation will-serve:-Residence. 4"" Commerciat—.Otbar- <br /> Number of living units: _J' Number of bedrooms - <br /> fl to depth of 3 feet: SA.r1Dy C1A+s _Water table depth <br /> of w dap F <br /> CharacterZ <br /> SEPTIC TANK 0 Type/Mfg PO'L Cspacity�S--- lNo. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well /ZO Foundation '� Property Line <br /> f <br /> f LEACHING LINE No. b Length of lines �e '� r Total length/size ZO , <br /> . j . <br /> • FILTER BED ❑ Distance to nearest: Well--kViL:� Foundation ___L12 Property Lina <br /> 1 SEEPAGE PITS I Depth - L —Size _ _ Za `r Number -� <br /> SUMPS L1 Distance to nearest: Well. 1.5e 7"- Foundation tog!` Property Line 2a � -- <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 fallowing: "l 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 workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: 111 certifythat 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 must call for all required inspections. Complete drawing on reverse side. <br /> Date: <br /> I FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data 2 Area -21 - <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> &17 AT3 <br /> I Additional Comments: <br /> Applicant --Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Per t/Services <br /> 445 H San Joaquin, P O 13 x 2009, Stkn, CA 95201 <br /> r <br /> e FEE A OUNT DUE AMOUNT EMITTED CA RECEIVED BY DATE PERMIT'NO. p <br /> IN O <br /> + EH 13-24 IREV.I/w be r <br /> EH 14.25 <br />