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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 O BOX 2009, STOCKTON, CA 95201 <br /> _PERMIT E%PIRES 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. <br /> sl �d1, <br /> Job Address City)n,d "— Lot Size/Acreage <br /> Owner's Name .,--.,/ ,�- Address -Z L e �� /�LrG;r phone 25 f + <br /> Contractor} z�1 -41tlt 4 Address i e�e No. %nPhone d'7ltf" <br /> TYPE OF WELL/ M NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well D <br /> PUMP INSTALLATION O SYSTEM REPAIR OTHER O Monitoring Well D <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 /> L7 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> tl Domestic/Private O Gravel Pack D Tracy Type of Casing_ Specifications <br /> I'1 Public fl Other n 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 �' Type of Pump�j/L��_ H.P. State Work Done Vit' <br /> Well Destruction D Well Diameter Sealing terial i Depthr <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTA LATION I I REPAIR/ADDITION ( I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Otheravailable within 200 feet.) <br /> • <br /> Number of living units: Number of bedrooms <br /> Character of sod to ax- <br /> depth of 3 feet: Water table depth <br /> SEPTIC TANK D Type/Mfg Capacity ICY Tits <br /> 17 <br /> PKG. TREATMENT PLT.Cl Distance to nearest: G <br /> REC't9 I <br /> Well Foundation Pr M �t�� <br /> LEACHING LINE Cl No. 8 Length of lines Total lej ANIJ <br /> FILTER BED ❑ Distarlpe to nearest: Well Foundation P pljR j TH SERV! c <br /> ENVIRONMENTAL i 7�`0``j <br /> SEEPAGE PITS I I Depth Size Number o <br /> SUMPS LI Distance to nearest: Well Foundation Pro <br /> DISPOSAL PONDS O party Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la ` <br /> rules and regulations of the San Joaquin County ws, and <br /> Homs 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 or subcontracting 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 Irst call for all required inspections. Complete drawing on reverse sid . <br /> . r <br /> Signed <br /> Title: Q- �'�?a�-° Date: <br /> FOR PA E ONLY <br /> Application Accepted by < > �- <br /> Date rA <br /> / <br /> Pit or Grout Inspection by Date + Final Inspection by � <br /> Date S � <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 <br /> INFO C SH RECEIVED BY DATE PERMIT'NO. <br /> . EM 1 .24 IREV.1/045)f� �/ /�,�,/ ` <br /> EH 11.25 �` J ./��; 7`� in � <br />