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. i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION j <br /> 445 N SAN JOAQUIN* PHONE (209)468-3420 <br /> I P O BOX 2009, STOCKTON, CA 95201 <br /> f ; <br /> PERMIT EXP I RES l YEAR FROM DATE <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 cospliance 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 City Lot Size/Acreage <br /> t , <br /> w is Name �� t�f'�--�� ess � �• ha <br /> Cc tract r `fid r FZ� No. p <br /> W,..,aehone <br /> TYPE OF WELL/PUMP: NEW WEL WELL 1EP1 ACEMEN ❑ DESTRUCTION ❑ Out of Service Yell 0 ! <br /> PUMP INSTALLATjONr „ SYSTEM REPAIR 0 OTHER O Monitoring well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL 4PROBL`EMAREA—CONS TAUCTION-SPECIFICATIONS. <br /> 0 Indust ' Its ❑ Open Bottom 0 Manteca � +" Dia-"of Well Excavation Dia. of Well Casing <br /> atrc/Private Q Gravel Pack ❑ Tracy. Type of Casing_ Specifications <br /> I'l Cl Other fl Delta Depth of Grout Seal. Type of Grout <br /> Irrigation Approx. Dap l astern Su act 5otlI Installed by 04 <br /> Repair Work pone T 1 <br /> pa' Type of Pump � N.P. �t�T~', 'State-Work D .� <br /> Well Destruction '❑ Well Diameter * Sealing Naterial A Depth ! <br /> Depth ��'�< -,�" Tiller Material A Depth ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIAIADDITION I I• OESTRUCTION I 1 {No septicli permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will terve: 'Residence T' Commercial Other r <br /> Number of living units: Number of bedrooms <br /> Character of Boll to s depth of 3 fast: ' - r / Water table depth ` <br /> SEPTIC TANK ❑ TypslMfg ) �' Capacity No. Cornpartrriantf <br /> EKG. TREATMENT PLT. Q _J,, Method of Disposal <br /> Distance to nearest. f Well Foundation 'OProperty Line t i <br /> LEACHING LINE Cl No. a Length of lines length/size <br /> i <br /> FILTER BED © Distance to nearest� -Welt Foundation Property Lina „ <br /> SEEPAGE PITS I I Depth r Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance witli Sah,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 this permit is issued, i shall not ' <br /> ani 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 parsons subject to workmen'i Compensa- <br /> tion laws of California." r <br /> The app! at call Al <br /> all ed ins etions. Complete drawing on �j <br /> rev s' <br /> 17 A0 qla <br /> Signe Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Dats rea <br /> Pit or Grout lnspection by Date Final Inspection pat <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services " <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P Box 2009, Stkn, CA 95201 <br /> NFO FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT NO. <br /> e EN 1324(REV,t Rb! <br /> oa - <br /> fN 1l•a3 � `l�j( ' <br />