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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION F11' <br /> P O BOX 2009, STMKTON, CA 95201 J A N 2 5 ' <br /> -(209) 468-3447 <br /> PERMIT ESP E� S 1 YEAR <br /> VRQM E ISSUEJNVIRONMLN 6Af HAS Hyl <br /> (Complete in Triplicate) PERMIT/SERVICES <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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. r <br /> Job AddressWWI, City Lot Size/Acreage <br /> Owner's Name A , rams �[`/�, Phone <br /> Contra torly.. �/04 &ut� ICense fVo.`7-`e^ - Phone rl/ <br /> TYPE Of-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT/0 DESTRUCTION ❑ Out of Service Well C.1 <br /> PUMP 1NSTALLATIOfr� SYSTEM REPAIR OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES V'1 DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> -.� INTENDED USE-.­�YPE-OF WELL_=;_PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Sodom"'""~E)Manteca� Dia:o1 Well Excavation Dia. of Well Casing <br /> masticIPrivate 0 Gravel Pack x,,,,,__0_Tracy,., _A. Type of Casing Specifications <br /> IM Public Cl Other c© Delta ~} Depth of Grout Seal Type_ of Grout <br /> Ml trrigation ,_.._.Approx, Dept--C] Easiern '^ Surface Seal Installed by V� <br /> Repair Work Done U Type of Pump H.P. State Work Dona <br /> Welt Destruction 0 Well Diameter Sealing Material i Depth r <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION 0 (No septic system permitted if public sewer is rn <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial — Other <br /> Number of living units; Number of bedrooms ` <br /> Character of soil to a depth of 3 feet: -- �Water table depth <br /> SEPTIC TANK 0 Typi/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT.Cl "Method of Disposal <br /> Distance to nearest. Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Totat-length 4size- <br /> i <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size <br /> SUMPS Ll Distance to nearest: Well Foundation ' Property Line <br /> DISPOSAL PONDS 0 <br /> 1 hereby certify that I have prepared this application and that the work.will be done in accor_dancevyiih-San_Joaquin-county_ordinances,-state.,tavv"nd. <br /> - —--9 - - r---- - == - <br /> rules end regulations of the en Joaquin County <br /> Home owner or licensed agent's signature certifies the loliowing: "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 subiecrto 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 /> The appy+can t c I fo all requue4 inspections, Complete drawing on revigae side. <br /> - <br /> Signe � p .. -- - Title: Date: -9 - <br /> F09,RARTMENT USE ONLY / <br /> Application Accepted by Data -Z / Area 1 _ <br /> Pit or Grout Inspection by Date Final Inspection by 09Z_� Date? <br /> Additional Comments; - <br /> Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 H SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIrTEO C SH RECEIVED BY DATE PERMIT'NO, <br /> INFO <br /> . EH 1 .24 tREV. 41 "1 <br />