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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ,f <br /> Job Address 1 Y � Q b � rf%R _ City z"'� Lot Size/Acreage <br /> .Q -^7V - `Y r� y <br /> Owner's Name s �A Address / 5�64ne <br /> Contractor Address �%,"" } License No.3 +f 5 Phone <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTIOOut of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ <br /> CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (I Domestic/Private ❑ Gravel Pack L-1 Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other r Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation �,Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Done _ SK Cys <br /> Well Destruction //K—Well Diameter Zrt Sealing Material i Depth . <br /> Depth 15—CP Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.! <br /> installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of Boil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 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 of sub-contracting signature <br /> certifies the following: "I Certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of C for la." <br /> The applica or all r uired i tions. Complete drawing on rave sid <br /> Signed Title: - - Date: <br /> C" <br /> FOF,DEPARTMENT USE ONLY ^7� <br /> Application Accepted by <br /> Date 1A- --93 Area 0 2-1 L 1+ � <br /> rr2r �/�- ate <br /> Pit or Grout inspection by Date Final Inspection by � � <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 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CEIVED BV DTE PERMIT NO. <br /> INFO j / U <br /> (REV.i <br /> A <br /> nsi I) lV 0 <br />