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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> RNWIT_EXP_I_RES I•,YEAR 999X DATE ISSUED <br /> ` (Complete in Triplicate) <br /> Application is hereby wade 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 /> t Joaquin County Public Health Services. <br /> Job Address r r City'F" ' �'r� tLot Size/Acreage 4� 01A, <br /> 711 a Owner's Name r .J `,�� Address _ _ Phone 70 ­ <br /> r ;. <br /> .y. of � <br /> 1 i <br /> l Contractor { 0� Address =11 7 ;ILL icense No. 33 Phone { <br /> 4 TYPE OF WELL/PUMP: WJM WELL ❑ WELL REPLACE NT C_1 DESTRUCTION.❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 /> E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> r <br /> Ll Industrial O Open Bottom 0 Manteca Dia. of Wall Excavation Dia:of Well Casing <br /> i 0 Domestic/Private O Gravel Pack 0 Tracy Type of Casing Specifications <br /> f M Public I'1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> Ci Irrioation �.Approx. Depth O Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H,P. State Work Done <br /> kWsll Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth { <br /> TYPE OF SEPTIC WORK: MEW INSTALLATION 0 REPAIR/ADDITION . DESTRUCTION G (No septic system permitted it public sewer is l <br /> available within 200 feet.) <br /> Installation will serve: Residence 1 Commercial IOther <br /> Number of living units: J Number of bedrooms J <br /> aCharacter of soil to a depth of 3 feet: �� � � _,.,.._ _ `�` ^ Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity _, - No. Compartments <br /> PKG.'-TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation 'Property Line <br /> LEACHING LINEAT No. 8 Length of lines 11 Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITSYDapth Size Number <br /> SUMPS L1 Distance to-nearest:-- Well -foundation Property Line <br /> E DISPOSAL PONDS O <br /> t 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 cenifies 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 subcontracting signature <br /> certifies the following: "I canify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The licant ust call for all requi i tions. omplets drawing on re se side. <br /> Sign Title: Date: ' <br /> OR D ARTMENT USE ONLY <br /> Application Accepted by iii. Date Area <br /> Pit or Grout Inspection by Date Final Inspection by� �_ �' __ . Date S <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 2008, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> • EH 13.24 I#EV.1/n S7 Q <br /> EH"Cue V c7 + 1 d <br />