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APPLICATION FOR PERMIT j <br /> + <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES q <br /> ENVIRONMENTAL HEALTH DIVISION I <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> : � 'A R <br /> I <br /> (Complete in Triplicate) <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 ccnpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations at San <br /> Joaquin County Public Health Ser' <br /> ea.5,i, <br /> S �rxdC T <br /> -n„ {j� �cS�•o -�� _ City�S' ►^ Lot Size/Acreage <br /> Job Address etl-Y fL -7 <br /> Phone VT-$3 f <br /> Owner's Name $� +b1^ Address f �7 <br /> C� 11� vSl�,1�4) L.fbgo 4+� Ld S�L� 4� <br /> w + 3 3 l Phone <br /> Conlraclor r Cc HaYor ress V%C C License No <br /> TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well <br /> D. <br /> "� ycur* --- PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK i t*Yl!_ SEWER LINES DISPOSAL FLOTHER WELL PITS/SUMPS <br /> FOUNDATION �" AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Zf:f <br /> ----~�----- Oia. of Well Casing I <br /> n Industrial C) Open Bottom O Manteca Dia. of Well Extt�� , <br /> Domestic Privat Cl Gravel Pack 0 Tracy Type of Casing ��11 <br /> TypeSpecifications <br /> Grout <br /> .— <br /> ❑ Delta Depth of Grout Seal TYIs of Grout <br /> �1 Public L" J?II Other/rf•LU-C <br /> vv1CM• .`N� Nu <br /> M luitiation ApprAx. Depth ❑ Eastern Surface Soul Installed by ` ' �/� — <br /> Repair Work Done U Type of Pump Ov H.P• State Work Done__ lille <br /> Sealing Material i Depth <br /> Walt Destruction O Well Diameter <br /> Filler Material i Depth <br /> Depth ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Cl DESTRUCTION Cl (No <br /> rwithin 200 feec system t.) it public sewer is i <br /> Installation will serve: Residence Commercial— Other <br />'(. Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Cl Method of Disposal <br /> PKG. TREATMENT PLT. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlsrty <br /> Lina <br /> FILTER BED C:1 Distance to nearest: Wall Foundation Properly <br /> SEEPAGE PITS 11 Depth Siie Number <br /> SUMPS UI 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, stale laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owns(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 persons subject to workman's compansa• <br /> tion laws of California." <br /> The applies ust call r all requirednsf pections. Complete drawing on rayerse aide. <br /> Signed <br /> [Ir7 Title: E/�`F Date, Q I <br /> FOR DEPARTMENT USE ONLY // / <br /> Application Accepted by . <br /> r .r' Date Ara6rJs <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> { <br /> Additional Comments: <br /> Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN. P 0 BOX 2049, STUCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEO LK 9 RECEIVED 9Y DATE PERMiY'NO. <br /> INFO <br /> ..Fit t]•71 1rrEY.���sr iJel <br /> ✓i '{� <br /> fi+;1.2or 1 <br /> e <br /> . ( ' <br />