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APPLICATION FOR PERMIT <br /> SAN jOAQUIN COUNTY=PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 9)468 <br /> p 0 BOX2009, STOCKTON, CA <br /> V095201-3420 <br /> EXP RES ] YEAR FROM A BD <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 cowliance'vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. i <br /> /yry� S Cit Lot Size/Acreage <br /> Job Address _! / Q �r <br /> CT Phon�N� / ! d✓/.'� <br /> Owner's Name <br /> Address j <br /> 0313 Phone 7 <br /> iPl,(//�(1 dress F v License No. �— <br /> Contractor DESTRUCTION ❑ Out of Service Weu ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT J Monitoring Well <br /> SYSTEM REPAIR © �OTHER ❑ / <br /> PUMP INSTALLATION ❑� f--A PROP. LINE'�-Z <br /> SEWER LINES - -- DISPOSAL FLD, <br /> DISTANCE TO NEAREST: SEPTIC TAN PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL+ OTHER WELL <br /> INTENDED USE TYPE OF WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICAT2_0I• NS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> Graves Pack L1 Tracy Type of Casing arlr*E <br /> li )<Domestic/Private 9 Type of Grou <br /> t.1 Other rl Delta Depth of Grout Seal <br /> I'1 Public rLL S <br /> I I Irrigation -o Approx. Depth t I Eastern Surface Seal Installed by <br /> H P State Work Dona <br /> Repair Work Done ❑ Type oil Pump �---- - Sealing Material 14 Depth <br /> Well Destruction ElWell Diameter Filler Material 5 Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRlADDITION l I DESTRUCTION I i availableic system w thin 200 feet.)redit public sewer is <br /> Installation will serve: Residence. Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size ' <br /> LEACHING LINE ❑ No. 8 Length of lines Property Line <br /> FILTER BED [I Distance to nearest: Well Foundation <br /> 1 t <br /> SEEPAGE PITS I I Depth Size Number <br /> hWell Foundation Property Line <br /> SUMPS l f Distance to nearest: <br /> /DISPOSAL <br /> / PONDS Cl <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, ander <br /> rules and regulations of the San Joaquin County <br /> ' Home owner or licensed agent's signature certifies the following: "I certify that in therformance of the work for which this permit is issued, I shall not <br /> e p <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature r 1e <br /> certifies the following:111 cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-V ' <br /> ti sof California." <br /> s T e app nt mu call f r It required inspections. Complete drawing o verse side /3r 9� <br /> Title: Date: <br /> Sig <br /> i <br /> f FOR gPARTMENT USE ONL <br /> Date_ Area <br /> A i ion Accepted by C , <br /> 4 � Data jD <br /> Pit or Grout Inspection by Date 1 Z3 Final Inspection by --- <br /> Additional Comments: <br /> Applicant - Return all copies to: an Joagti, County Public Health <br /> Services, Environmental Health Permit/Services- <br /> 1601 <br /> ermit/Services1601 E. Hazelton Ave., P Box 2009, Stockton, CA 95201 <br /> FEE MOUNT REMITTED K RECEIVED BYHDATEEPERMIT'NO. <br /> INFO AMOUNT DUE <br /> rY�EH 13.24{REV.I A5) 3 `j 9'0' 9 <br /> EH:�-ZB <br />