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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES )4 <br /> ENVIRONMENTAL HEALTH DIVISION 0".-C <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 Z® <br /> P O BOX 2009, STOCKTON, CA 95201 SAN�P 18199 <br /> PERMIT EXPIRES 1 YEAR FRAM DATE ISSUF VI d��E���� CO�2T}� <br /> (Complete in Triplicate) T,q�ygSERVF�� <br /> C Tyl� S J <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein descri -This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San <br /> Joaquin County Public Health Services. 1 4 <br /> Job Address C- eLJ &PA <br /> City Lot Size/Acreage <br /> Owner's NameAddress <br /> �nlf tt e�l'LI r fit Phone <br /> Contractor Address L AlLicense No.=14.1-_Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL•REPLACEMENT rl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED=USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M duarial t ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public El 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 U : Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter" !f Sealing Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION E_I_(No septic system permitted if public sewer is <br /> svailable'withih-200 feat.) <br /> Installation will serve: ;Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of aom to a depth of 3 feet: f Water table-depth <br /> SEPTIC TANK O Type/Mfg Capacit, No. Compartmoots <br /> PKG. TREATMENT•PLT.0 += f Method of Disposal <br /> Distance to nearest: Well Foundat on <br /> Propertq�tine <br /> LEACHING LINE ❑ No. & Length of lines Tojal length/size � <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property-Line <br /> f <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line # <br /> i <br /> DISPOSAL PONDS ❑ <br /> I hereby comity that I have prepared this application and that the work will be done in accordance with San Josquin;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-worklor which this permit is issued, I shall not <br /> l 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 foNo g:"I certify that in the performon_co'of the work for which this permit is issued, I shall employ persons subject to workman's compensa- a. <br /> tion laws C is... <br /> The spplic t it can for all reqinspect' . Complete drawing o v r side. <br /> t , <br /> Signed q-11- <br /> Title: Date: <br /> RS + ) <br /> FOR REPARTME USE ONLY <br /> Application Accepted by $ Date y✓ �� Area <br /> Pit or Grout Inspection by Date Final Inspection by y Dats1 D 0 j 1 <br /> f <br />` Additional Com'nlerits: <br /> Applicant Return all copies to: Sao'Jonquin County Public Health Services <br /> f ; Environmental Health Permit/Services ���yy,•y�� <br /> 445 N San Joaquin,"P 0 Box 2009, Stkn, CA 95201FEE <br /> INFO-' ' AMOUNT DUE AMOUNT REMfTTED CASH RECEIVED BY DA,T.E) PERMiT'NO. <br /> . EH 19-21 iREV.1/04 02 � r 5 <br /> EH t1•Ze <br /> l <br />