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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION t <br /> P O BOX 2009, STOCKTON, CA 9.5201 <br /> (209) 468-3447 <br /> P, gT ERPIRES 1 YEAR I?fiQ ,DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This � <br /> application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules Lad Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address `-' �+,�:✓�L X19i I City _ Lot Size/Acreage <br /> `r wner's Name 7 r''� � ` Address S i,l �iPllone O�27 r <br /> Ap r l`C. -- - <br /> Contractor r Address � ( L6 License No. Rhone <br /> TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENTn DESTRUCTION ❑ Out of Service, Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well o <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dig. of Well Excavation Dia..of Well Casing <br /> U Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing Specifications Q) <br /> M Public la Other ❑ Delta Depth of Grout Seal Type of Grout Q <br /> C! Irritaation _ Approx. Depth O Eastern Surface Seal Instalidd by <br /> Repair Work Done U Type of Pump H-P. State Work Done r <br /> Wail Destruction © Wall Diameter Sealing Material a Depth <br /> Depth Filler Material R Depth <br /> FPKG. <br /> EPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 . DESTRUCTION G Mo septic system permitted if public sewer is <br /> / available within 200 loot.) i <br /> Installation will serve: Residence ✓ Cammarcial_. Other 45 <br /> f living units: � Number of bedrooms <br /> of soil to a depth of 3 feet: .... rf l�J+�+l Water table depth «� y <br /> NK, CYfype/Mtg �� - ' Capacity._1_ZI1C T/ No, Compartments TMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation.. .� Property Line � <br /> LEACHING LINE 2No. & Length of lines � Total length/size x� ,/ b <br /> FILTER BED Distance to nearest: Well 1�' ' Foundationka l._� Property Line Jif <br /> SEEPAGE PITS Size j Number__S,Z- <br /> SUMPS LI Distance to nearest: Well ZIM Foundation [L _ Property Line ^7-f <br /> 1� DISPOSAL PONDS ❑ <br /> I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County l <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 shall 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 /> certifies the following: "I certify that in the performance of the work for which this pormit is issued, I shall employ persons subject toworkman's compensa- <br /> tion laws of California." <br /> he applicant sl call for all required ins cti ns. Com fete drawing on reverse side', <br /> P(S <br /> igned r ,fit r 1� Title: JLDate:I., <br /> FO EPARTMENT USE ONLY <br /> Application Accepted byO�C4A_ .�a.A _ _ Date ��~ Area <br /> PIVor Grout Inspection by ���Date Final Inspection byp <br /> Additional Comments: -2 <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 EIOX 2009, STOCKTON, CA 85201 <br /> FEE <br /> INFO AMOUNT DUE AM UN7 REMITTED CASH RECEIVED 9Y DATE PERMIT'N0. <br /> r EIi 17-2t IAEV. <br /> Ek:LZts [�?t lzU-­9-q I qv-33 <br />