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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �� r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 N <br /> (209) 468-3447 ' <br /> YEAR D <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 4 City of Size/Acreage .9:2:iL <br /> Owner's Name '��-� A-16sv+ -Q Address ---+ � Phone <br /> i <br /> Contractor Address License No. V Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C_l DESTRUCTION Kout of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -- DISPOSAL-Ft•D:-- - -PROP. LINE <br /> FOUNDATION AGRICULTURE WELL^ OTHER WELL PITS/SUMPS .T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SP>ClFICATIONS <br /> f.1 Industrial ❑ Open Bottom ❑ Manteca Dia,-of Well Excavation Dia. of Well Casing <br /> U Domestic/Private Cl Gravel Pack. El Tracy s Type-of-Casing z Specifications <br /> M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation _ _.Approx. Depth 4n Eastern Surface Soul Installed by <br /> Repair Work Done L] Type of Pump t H.P. State Work Done <br /> Welt Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.)D ,REPAIRIA001TION 0 OESTRUCTION INo septic system permitted it public sewer is <br /> vaifable within 200 feet.) ( <br /> Installation will serve: Residence— Commerciit Other V / <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feel. Water table depth <br /> SEPTIC TANK Q Type/Mfg Capacity No. Compartments i <br /> PKG.TREATMENT PLT. 0 '" Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of,llnes . Total length/size <br /> FILTER BED C_1 Distance to nearest: , Well Foundation Property Line <br /> SEEPAGE PITS 1 1 Depth <br /> _ Size � V Number <br /> SUMPS " •LDstance tonearest_ Well Foundation `line—Pt <br /> DISPOSALPONDS w❑ <br /> I hereby certify that I have preparedthis applicatlon and thmrt'.Jhe.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 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 compensa- <br /> tlon laws of California." <br /> The applicant must call for all rqqpred ins coons..Complete drawing on reverse side. <br /> Signed X <br /> - ,r:�;?Q.r!ea�h Title: ��j�1�(���d �,... Date: /9 <br /> F fi D>E LY <br /> Application Accepted by Date4 {' (.y Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: Wap q <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 95201FEE <br /> _ y <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �• <br /> EH 17.24 IREV.r i e Sl <br /> EH 14.E 'c C� t C7C� �� Fld <br />