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•.s 4 1� <br /> I 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 /> PEUIT EXPIRES I -YEAR PROM DATE laaUED <br /> (Complete in Triplicate) <br /> Application is hereby trade 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 Sar: <br /> Joaquin County Public Ij�al�� r �, <br /> Job Address City 577(nm e Lot Size/Acreage <br /> Owner's Name ` dress —!_�lLRDX /�iz Phone <br /> Contractor CA�1 51ie / /ll/y/—Address 3? S nse No-;L),G,2A--2 Phone <br /> TYPE OF WELL/PUMP NEW WELL '-) WELL REP AGEMENT 7 DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f� Industrial V Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing <br /> U Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing VIM Specifications <br /> M Public CI Other 0 Delta Depth of Grout Seal Type of 140ut <br /> M Irrigation Approx, Depth d Eastern Surface Seal Installed b T <br /> Repair Work Done U Type of Pump H.P, State Work Do <br /> Well Destruction 9&. Well Diameter �_ Sersling Material fr Depth , a <br /> Depth �'`~ Filler Material fir Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION Cl DESTRUCTION No septic system permitted it4mf5ilic sewer is <br /> av <br /> Installation will serve; Residence — Commercial — Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _.._._Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1i Depth Size Number <br /> SUMPS LI Distance to nearest: Well FoundationPro <br /> DISPOSAL PONDS ❑ party Line <br /> I hereby certify that I have prepared this application and that the work wall 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 CaWornia." 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 appli u cat or all r lied inspections. Complete drawing on re rse side. <br /> Signed Title: C C <br /> .�„_. Data; <br /> OR DEPARTMENT USE ONLY <br /> 44tA�t�Application Accepted by <br /> Datea <br /> Pit or Grout Inspection by Date 3 <br /> Final Inspection by Dats���y� <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 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> }NEO CASH RECEIVED 9V DATE PERMIT N0. <br /> EM <br /> + EH t]d1INEV.ileal <br /> ',4,x <br />