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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ,r n 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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 coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County/Public <br /> /Health Services. IVJ <br /> Job Address ! ! (n —J '°' City Lot Size/Acreage <br /> Owner's Name <br /> S4 �� �3/ Address/ e� so.L! "mac • Phone "--,CJ7 <br /> Contractor f Address License No.y Phone <br /> TYPE OF WELCPUMI NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR OTHER O Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I-) Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> VDomestic/Private O Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> Il Public f-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ut _ Approx. Depth I Ea tarn Surface Sen Installed by 14 <br /> Repair Work Done a Type of Pump ' H.P.�� Stat or one <br /> Well Destruction O Well Diameter Sealing Material i Dept — <br /> Depth Filler Material i Depth, tri-az IQ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INW 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"If to a depth of 3 feet: Wa�wsfatleBdf <br /> SEPTIC TANK. O Type/Mfg Capacity No //11 i 1Y1 <br /> PKG. TREATMENT PLT.O M � E <br /> Distance to nearest: Well Foundation Property 14AQ.2--7 —t�p�l -'> <br /> LEACHING LINE ❑ No. 6 Length of lines Total'leng, SFiRVIr <br /> FILTER BED O Distance to nearest: Well Foundation EM"MENIA1 HFAI TH DIVIS01 <br /> SEEPAGE PITS I I Depth Size Number 4 <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby certify that 1 have prepared this application and that the ork will be done in accordance with San Joaquin county ordinances, s&aate 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, 1 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 following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compenss- <br /> tion laws of California." <br /> The applicant mat call for/al uired inspections. Complete drawing on reverse side. <br /> Signed X n L t/` 'c' Title: �(�t +�'�' Date: S2;F,!91" <br /> F R DEP MENT EON <br /> Application Accepted by Dt)ts res <br /> Pit or Grout Inspection by Date Final Inspection by Dat <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, ox 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY D TE I PERM17 N0. <br /> . EH 1324(REV. /n 5l / t i <br /> EH 14.26 <br />