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( 2 9—2-06 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM 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. t <br /> Job Address _- It -\ 1�� _W- City _ Size/Acreage <br /> Owner's Name �, Address D)G Z J DStn t tQ. Phone <br /> Contractor rr Address_�10 D©)1917Li No./0,3_73 Phone -q 1 <br /> TYPE OF WELL/PUMP: NEW WELL / WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR O OTHER O Monitoring Well (� <br /> DISTANCE TO NEAREST: SEPTIC TANK IA, rm "� SEWER LINES I Bbl +' DISPOSAL FLD.I Dom-}PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI N P-i (� <br /> ndusthal O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private *<',avel Pack 0Tracy Type of Casing c Specifications G <br /> M Public ('I Other &16 lta Depth of Grout Seal 110001 Tye of Grout r1 I <br /> CJ Irrigation Approx. Depth ❑ kastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump A H.P. C State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth yam, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0EPAI / Dmm <br /> ON M 0 TRUCTION_CI (No septic system permitted if public sewer is V� <br /> I within 200 feet.) <br /> Installation will serve: Residence_ Commerci t <br /> tu <br /> Number of living units: Number of bedrooms <br /> Character of*oil to a depth of 3 feet: Nr it ma h ' Water table depth V� <br /> SEPTIC TANK ❑ Type/Mfg fps ed' <br /> Method <br /> Compartments n <br /> PKG. TREATMENT PLT. O ° ' ` �✓ <br /> ,/ } Method of Disposal <br /> Distance to nearest: ID f1Vl� uhd6 vii DIV!$� rty Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED C) Distance to nearest: Well oundatio Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well HEFoundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that t e work will be done in accordance w San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or ant'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 raon in such nner as to become su t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifier th for <br /> "I cs ify that int pertor nc of the rk for which this permit is issued, I shall employ persons subject to workman's compenss- <br /> tion laws of California." <br /> The sp icant I or all r to drawing si <br /> Signed Title: Date: l <br /> C} <br /> Application Accepted byR—)!�m"T USE ONLY Data I^�11/ Area _ <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 REMiTTEO CK <br /> INFO 4100 <br /> �/y/// CASH RECEIVED BY /DATE /y} PERMIT'NO. �y <br /> . EN 14.21 It1EV.rinSl !L <br /> E1,114-2111 G j' <br />