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APPLICATION FOR PERMIT • -, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �[ ENVIRONMENTAL HTALTH, DIVISION <br /> 445 N SAN JOAQUIN, PHONE.{209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE I 5 <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 Health Services. <br /> j <br /> i Job Address _, <_ � City •~ Lot Size/Acreage �LC <br /> jL <br /> Owner's <br /> Na Address ®� t{ ► l �7LrCl Phone <br /> Contractor Address <br /> —Phone <br /> LO <br /> .,« TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EI DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> N <br /> FOUNDATION AGRICULTURE'WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA "CONSTRUCT ION�SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom "� ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack 1. ❑ Tracy Type of Casing_ Specifications <br /> i'1 Public f"1 Other n Delta Depth of Grout Seal Type of Grout <br /> I l Irrigation Approx. Depth I l Eastern Surface Said installed by <br /> Repair Work Done 0 Type of Pump H.P. Stats Work Done_ — <br /> s Wall Destruction ❑ Well Diameter Sealing Material i Depth t� <br /> Depth Filler Material i Depth <br />` TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> i available within 200 feet.l <br /> Installation witl serve; 70Number <br /> a�C ,Cornmerciel OtherNumber ofRvinq units: of bedrooms <br /> s Character of$od to a depth of 3 feet: Water table depth " <br /> SEPTIC TANK. ❑ Type/Mf L <br /> 9 Capaci No. Compartments 00*1 <br /> PKG. TREATMENT PLT.❑ Method of Di !" <br /> r d, sgosa! <br /> JET <br /> Distance to nearest: Well I_ Foundation�� Property Line_ 5.. .r.,,,... . <br /> LEACHING LINE No. m Length of Tinea Total length/size-- <br /> 4 <br /> ength/size <br /> FILTER BED Distance to r� <br /> . , �. nearest. Well 4K,�7=7Founda'tion �, Property Line <br /> SEEPAGE PITS, 11 Depth /�/ Size 45", ve - Number Cf•'FjCl2�[8r <br /> SUMPS Distance to nearest: Well Foundation Su F r <br /> � i <br />' Pr `� <br /> o Line � <br /> pe <br /> DISPOSAL PONDS /❑ J <br /> I hereby certify that I have prepared this application -= <br /> and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and <br /> rUlei 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 shell not <br /> <empfoy,any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cinifies 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 eomponsa <br /> tiori laws of California." <br /> I' The applicant must call for ail require inspect, s. Complete drawing se side. <br /> Signed ' Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by F Date5&A vC<� <br /> Area <br /> Pit or Grout Inspection by Date�. Final Inspection by Data'33 <br /> t - .e . f •.� <br /> Additional Comments: z <br /> f •• w. .•wk� <br /> }Applicant - Return all copies to: :,San Joaquin`ColintylPublic Health Services <br /> Environmental He'alth'Permit%services <br /> +� 4.45 N San Joaquiti O Box 2009, $t1t11, CA 95201 <br /> IEEE" AMOUNT DtJE 'T AMOUNT REMITTED K RECEIVED BYa,3 <br /> PERMIT'N0. !� <br /> INFO r E►4 14.2 tR1cV.ileal � fT1,07 � <br /> EK 1�•2a <br />