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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��Y <br /> ENVIRONMENTAL HEALTH DIVISION ENY <br /> P O BOX 2009, STOCKTON, CA 95201 RECEIVED <br /> (209) 468-3447 NOV16 1992 <br /> YEAR PRO PATE ISSU SAN JOAQUIN CCt,N7-y <br /> (Complete in Triplicate) HEALTH sERVlCFS <br /> EN'v1R0N E T� 1� <br /> Application Is hereby made,to San Joaquin County for a permit to construct and/or install the vont�e49F-f ea �� rr'�tj'L�fThis <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. <br /> Job Address `S Lo ''� City Lot Size/Acreage <br /> In� <br /> ,_�.C �--AddressOwners NamePhone <br /> G Adres icense N�3!F Phone <br /> Contra <br /> TYPE OF WELL/PUMP: <br /> NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L;' OTHER ❑ Monitoring Well 0 <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 /> 0 industrisi ❑ Open Bottom ❑ Manteca Die. of Weil Excavation Dia, of Well Casing <br /> mestic/Private ❑ Gravel Pack 0 Tracyt Type of Casing Specifications <br /> M Public is Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation 'Approx, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done &---Type of Pump r H.P, Za— State Work Done W <br /> Welt Destruction 1) Well Diameter Sealing Material.& Depth <br /> Depth Filler Material & Depth V{ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G iNo septic system permitted if public sewer is <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 ❑ Type/Mfg Capacity No. Compartments <br /> .,PKG. TREATMENT PLT, 1-1 rt Method of Disposal <br /> Well Foundation Property Line <br /> Distance to nearest: <br /> LEACHING LINE Cl No. & Length of lines' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS ❑ <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 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 Celifornia," 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 applicant m II required inspgction . Complete drawing on re se side. f <br /> Signed Tida: -- Date: <br /> POR DEPARTMENT USE ONLY <br /> Application Accepted byDate �! Area <br /> Pit or Grout Inspection by date Final Inspection by ate�,< <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> CK <br /> INFO <br /> FEE AMOUNT DUE AMOUNT <br /> ++REMITTED CA.SRECEIV,yE�D8Y DATE / PERMIT'NO, <br /> r EMt9.24tREV.1/Ftp 166 + V Z � 3. [�yH C <br /> -7 6/6 <br />