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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES "Ef V <br /> ""ri <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 APR 1 .�'� <br /> R 9JR09 pATE ISSUSD ENVIRONMENTAL HEALTH <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. <br /> Job Address of?�� W / ----- City Lot Size/Acreage <br /> Owner's Name VP3:3:jd414­.4-A_- `'"'�!�•— Address — Phone <br /> Contract r,. ddressLicense N4. Phone �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT nJ _ DESTRUCTION Cl Out of Service Well Gl <br /> PUMP INSTALLATION P--' SYSTEM REPAIR L� OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSYSUMPS .._ ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Uastir/Private C1 Gravel Pack ❑ Tracy Type of Casing Specification <br /> s <br /> Zc ("I Other 0 Delta Depth of Grout Seal Type of Grout <br /> CJ Irrioation � Approx. Depth 0 Eastern Surface Soul installed by <br /> Repair Work Done Type of Pump ,r. H.P. State Work Done CA <br /> U-1�� <br /> Well Destruction 0 Well Diameter Sealing Material Ile Depth V' <br /> Depth Filler Material i Depth CA <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0DESTRUCTION CI (No 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.C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. b Length of lines Total length/size r f} <br /> FILTER BED n Distance to nearest: Wall Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Sire Number <br /> SUMPS Li Distance to nearest: Welt Foundation-- ,Property Line _ <br /> DISPOSAL PONDS ❑ <br /> 1 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 Sen Joaquin County <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 compensa- <br /> tion laws of California." <br /> The applicant must call fa 11required insptctions. Complete drawing on reverse side. <br /> Signed X 61 _ Title: _ � Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date / Arae <br /> Pit or Grout Inspection by <br /> Date Final inspection by Dats 2`� <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 O BOX 2009, STOCKTON, CA 95201 <br /> INFO 1EEAMOUNT DUE AMOUNT REMtT'TFD CASFI RECEIVED BY DATE PERMIT'NO. <br /> . EM 1374IIIEV,r/n5) il C��►�";FC, /r'� q <br /> EM 14-M <br />