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_ f APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> v ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 Y <br /> i <br /> R M DATE <br /> (Complete in Triplicate) <br /> 2-(05/20 — <br /> Application In 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> _ s -�- ems- �. U <br /> J b Address � City �-�'�V'��_)S Lot 3ise/Acreage <br /> Owner's Name Y"::(Az Address Phon <br /> I Contractor Address G1i License No. Phoned <br /> TYPE OF WELL/PUMP. _ _ NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION 0 Out of Service well Q <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR l7 OTHER Monitoring Well [1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSa <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Sp-� <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of WiMExcavation l <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. /r�hi�-Z _ Specifications 1 <br /> 0 Public Cl Other 0 Delta Depth I? Type I Grout S <br /> CJ Irrigation —.Approx, Depth 0 Eastern ;C7 <br /> k Repair Work pone U Type of Pump H.P. State Work 0 na <br /> ' Well Destruction O Well Diameter Sealing Material i Depth ` <br /> ' Depth Filler Material i Depth { 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION i-1 DESTRUCTION U INo.sepric system permitted if public sewer is i <br /> available within 200 feet.l <br /> Installation will serve: Residence Commercial_._, Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth Q <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, 0 Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE Cl No. 8 Length of lines _ Total length/size <br /> FILTER BED ❑ Distance'to nearest: Well Foundation Property Line <br /> ' SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have? p',�,Afed this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and regulations of e n Joaquin Co <br /> Home o4perso'n""'. <br /> t's signature - Fes following: "I certify that in the performance of the work for which this permit is issued. I shall not <br /> employ anner as I biect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifiesfy that' th mance of the work for which this permit is';sewed,t shall employ persons subject to workman's compansa-tion lawThe appI r Complete drawing on r side.Signed Title: v ,T Date: xxxclAR6 <br /> i � FOR DEP AR E �E ON Y <br /> Application Accepts by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Dater D Qo <br /> Additional Comments: o <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> ` <br /> INFO AMOUNT DUE 1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> 7. <br /> • E„1`. iREv., KS, ?�– <br />