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60 <br /> APPLICATION FOR PERMIT <br /> SAN .TOAQUIN COUNTY EN'VIRONMENTAL HEsLALT DIIC MS ON VICES SCANNED <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (249) 468-3447 <br /> Y R rROX 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 cesTpllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /I j� <br /> $(p� ��BOJ City Lot Size/Acre e /!. TI <br /> Job Address <br /> Owner's Name C �_ n r n i l k i Address �-�-�- L Phone �- <br /> Contractor <br /> ��& Address G-off / IL��'1� License No.�/�_Phone / Z" 6 <br /> TYPE OF WELL/PUM : NEW WEWELL REPLACEME DESTRUCTIO tot Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES t DISPOSAL FLD.,, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ,(� OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION§. A <br /> n Industrial Open Bottom ❑ Manteca Dis. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing � '��_ Specifications. <br /> R Public f-1 Other 0 Delta Depth of Grout Seal X17 L;f_ ____ Ty of rout <br /> '"Is i0ation Approx. Depth Cl Eastern Surface Seal Installed by <br /> ' Aspair Work Done U Type of Pump H.P. State Work D <br /> Weft Destruction O Well ' Star Sealing Material i Dept <br /> pth Filler Material pth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAiWADDITION 0 DESTRUCTION G (No septic system permittgcuf public sewer is {� <br /> available within 2 r r <br /> Installation will serve: Residence— Commercial Other 1_A�tI <br /> Number of living units: Number of bedrooms \ <br /> Character of $oil to a depth of 3 feet: Water table depth V <br /> SEPTIC TANK O Type/Mfg pacify No. Compartments \V\ <br /> PKG. TREATMENT PLT. C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Len�fi Total length/sire <br /> FILTER BED 11 Distance tWell Foundation Property Line <br /> SEEPAGE PITS 11 h Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I eve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 0 <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 taws 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must all Or d inspecti pate drawing on reverse side. �1 <br /> Signed �/` Title: —_`�� i Date: v <br /> O PARTMENT USE ONLY <br /> Application Accepted by 2 Date. � Area -- <br /> Pit or Grout Inspection by Date / Final In ion by Date <br /> Additional Comments: rA, <br /> Applicant - Return all copies o: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMiTTEO CASH RECEIVED BY DATE PERMIT NO. <br /> . EM 1 .24(REV. �{`j�� __-ALZ�`3b�� 4 b _3_0 5 <br /> f►r N•20 { <br />