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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONI[ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 . <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERIf T ESP I RE S 1 YEAR ERQK DT <br /> (Complete in Triplicate) <br /> f <br /> f Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. Thias <br /> application is made its coWliance with San Joaquin County Ordinance No. 549 and 11362 and the Rules and Regulations of San'! I <br /> Joaquin County Public Health Services. <br /> ������ J <br /> Job Address 114 ' a�-y- <br /> City jLf/ sat Size/Acreage �j' , <br /> Owner's Name �v �+� `" "xlddressPhone ="f <br /> Contractor ddress O ,V-2/9 f!r-�f _License No.„gw"IeV Phone' r' z <br /> TYPE OF WELL/PUMP: ', NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 f <br /> } PUMP INSTALL�=.S�iWER <br /> SYSTEM REPAIR E1 OTHER El Monitoring Well ❑ <br /> DISTANCE TO-NEAREST: SEPTICITANK LINES DISPOSAL FLO. - PROP. LINE \� <br /> FOUNDATION `�.S�d- AGRICULTURE WELL OTHER WELL PITS/SUMPS �f A <br /> { <br /> i <br /> ! INTENDED USE .TYPE OF-WELL ,PROBLfcHtAREA CONSTRUCTION SPECIFICATIONS � <br /> 0 Industrial r , ,. ❑ Opsri Bottom- ❑ Manteca Dia. of Well Excavation ��- Dia. of Well Cas,n <br /> /)"omestic/Private ravel Pack �---C7 Tracy Type of Casing_ �t� Specifications G�� (�► <br /> CI Public ` /fgl_Other-. i n Delta 1 Depth of Grout Seat s0 Type of Grout <br /> Repair`eW" k-"Dome'�13' -T�of tion .r Approx. I I Eastern- P riace Seal Installed Stat <br /> 0 Work Done _ <br /> Wed Destruction * ❑ t Well Diameter }Sealing Material i Depth ! <br /> #Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is \..J <br /> j _ ---� `"� .�• aviilable within 200 feet.l \ 1 <br /> Installation will sorye:'•-Residencs=Commercial Other <br /> Number,of living units: Number of bedrooms <br /> Character a sod to a depth of.3"fest: Water table depth <br /> SEPTIC TANK - ❑ TypNMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal ., <br /> i 1 <br /> Distance to nearest: Well� Foundation Property Line <br /> i <br /> l LEACHING LINE '' CI No. & Length of lines Total length/size C <br /> { FILTER BED t i 0 Distance to neareai:, WellFoundation Property Line <br /> SEEPAGE PITS r 1,rl I Depth Size' Number <br /> SUMPS `s .:LI Distance to nearest: Well i Foundation Pro 9 X <br /> party Line <br /> DISPOSAL PONDS :7 ❑ <br /> I hereby certify that I have prepared this application and than the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County I <br /> Home owner or-licensed f. agent's signature certifies the following; I! <br /> Be _ g: "I certify that in the performance of the work for which this permit is issued, E shall not.employ env 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 laws of California <br /> :I ,! <br /> The applica m o all rtions. Complete drawing on rev cse sideA. <br /> f ; q` is <br /> SignedTitle: Date: �`7 <br /> t,FpR DEPARTMENT US ONLY <br /> Application Accepted by i Date <br /> - Area <br /> Pit or grout Inttpectbn by ata Final Inspection by Date Y <br /> (/ F' <br /> ._...Addifioiiil Comments: _ -..._..��. - .:•.....----.......�_. � ...,.,-,. .._ �.. �..,....--.-...,-..,,,_T�.�...._�-�! <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Elivirogtnental Realth.Peimit/Services <br /> 445 N San dbaqum, P''O Box 2009, Stkn, CA 95201 i! <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO t:K RECEIVED 8Y DATE PERMIT"NO. <br /> EM1 -t1iREV,riedi <br /> EN-14-28 C /✓ 4�/a <br />