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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> /Ik PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> f' Application is hereby made to San Joaquin County for a permit to construct and/or install the Mork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1864 and th Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address &6-C) -f } City 2&6=7 Lot Size/Acreage <br /> Owner's Name V� LI ✓j�c Address r Phone a �7� 9 L"� <br /> LIP- <br /> Contractor /C�� /1F+ 1� �1 Address /o 13� t7� License No.�?73k'r Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION t of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L] OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 4PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <br /> 0 Industriai ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia; of Well Casing <br /> [a Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing= Specifications ems. <br /> Il Public 1:1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> t <br /> I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction jik- Well Diameter sealing Material A Depth <br /> tfcTiller Material Depth A <br /> Depth --_`_3 c'7 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION [ I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> available within 200(set.) <br /> I <br /> Installation will serve: Residence_.._ Commercial_ Other <br /> Number of riving units: Number of bedrooms <br /> Character of sod to a depth of 3 feet: _L—Water tabls depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity ! No. Compertm4nts <br /> PKG. TREATMENT PLT.0 i Method'of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> � i f <br /> LEACHING LINE Cl No. 5 Length of lines Toial length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation I Property Line i rL. <br /> SEEPAGE PITS 11 Depth Sirs ' Number _j <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line _ <br /> DISPOSAL PONDS ❑ <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 Is 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 foitowing: -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." 1 <br /> The applicant must I for I required inspections. Complete drawing on reverse side. i1 <br /> r <br /> Signed Title: ®1/rf � Date: <br /> �( F AE.NT.USE ONLY u <br /> Application Accepted by Qt.., lA�. Date 1 IV— I <br /> „1a IyM, Area <br /> Pit or Grout Inspection by Date Final Inspection by Data t —6 70k J <br /> Additional Comments- <br /> Applicant <br /> ommentsi Applicant - Return all copies to: San Joaquin County Public.-Health Services rl-I <br /> Environment'a1,.Nealth Permit/Serylg4s <br /> 445 N San Joaquin, P O Boi 20W..', Stkn,)CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIV <br /> IEN ED BY DATE PERMIT'NO. <br /> a EN 1t�•Za 3-24 IItEV.1/1151 6 Q e �V �O C7, coo �" LV—�� t.-7 r <br /> �^' <br />