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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ur R'XPIRR I 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 to made in ecopliance with San Joaquin County Ordinance No. 549 a137d'1862 and the Rules and Regulations of San . <br /> Joaquin County Public Health Services. <br /> r <br /> Job Address Ll " City Lot Size/Acreage <br /> Owner's Name _ Address Phone <br /> t + �� ense ffo. �531r�G- Pho <br /> Contrac Addre Y <br /> TYPE 0 WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION © SYSTEM REPAIR <br /> OTHER ❑ C7 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestielPrivate,. O Gravel Pack _ ❑ Tracy Type of Casing Specifications <br /> M Public Ia.Otherf �• D Deltas J 9 y Depth of Grout Seal Type of Grout <br /> CJ Irrigation �"'.Approx• Depth 0 Eastern E.Sui,fa'co Seal Installed by <br /> Repair Work Done skT Type of Pump H•P• ��� ' - - State—Wo rk'Oonp- <br /> Welt Destruction ❑ Weil Diameter Sealing Material A .Depth <br /> Depth Filler Material &'Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ID REPAIRIADDITION 0 DESTRUCTION G INo septic system permitted it public sewer is <br /> available within 200 fesi.l ei <br /> Installation will serve:-w Residence— Commercial_____ Other <br /> Number of living units: Number of bedrooms .s� 1,{ , <br /> Character of soil to a depth of 3 feet: <br /> 1_, �� � Water table depth <br /> SEPTIC TANK- . ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 1..r<# Method of Disposal <br /> Distance to nearest: Well Foundation Properly Line <br /> { 1 Total fen th/size <br /> LEACHING LINE L'I No. & Length of fines j g <br /> FILTER BED ,n Distance to nearest: Well Foundation Properly Line <br /> 111111 SEEPAGE PITS it Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 _ <br /> ry I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r <br /> } rules and reguistions 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 /> 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 /> cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shill employ persons subject to workman's compensa- <br /> f tlon laws of California." <br /> 1 Thsapplicant m ■II�FOIIquired ispectio <br /> enns. Complete drawing on r ergo sib. <br /> I Signed Title: f <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> �f / _ Date l� �Z� Ares <br /> Pit or Grout Inspection by Date Final.Inspection by Date <br /> j Additional Comments: - <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRON14ENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 H SAN JOAQUIN, P O BOL 2009, STOCKTON, CA 85241 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK9 RECEIVED 8Y DATE PERM17 NO. <br /> INFO <br /> . EH 17-24IREV.i/Ksl jozo 9 9-s-: [ �' ' f 32- 6v 2--3-N8- <br /> EN 74� <br /> i <br />