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. t APPLICATION FOR PERMIT <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED <br /> 1992 <br /> ENVIRONMENTAL HEALTH DIVISION JUN <br /> P O BOX 2009, STOCKTON, CA 95201 tu <br /> (209) 468-3447 ENVIRONMENTAL HEAL, <br /> \A PE_MIT EXPIRES 1 YEAR PROM DATE ISSUED PER <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address X741 Sa• lea - City Lot Size/Acreage <br /> � <br /> • - , ► <br /> Owner's Name 10y ��"� Address�°o L��t�d.4 PAP ' -' Phone <br /> Contra c d--'__� ddre o i c e n s e N -2_ ' hone 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ID/ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well (3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> Ite> vomastic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> M Public VI Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Cl Irrioation .Approx. Depth ❑ Eastern Surface Seal Installed by \ <br /> Repair Work Done U Type of Pump ,am___eZ= H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is r /� <br /> available within 200 feet.) � J <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 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to newest: - W44 Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 <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 permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu o all required inspec ions. Complete drawing onn verse,side. / <br /> Signed CC Title: Date: <br /> EPARTMENT USE ONLY <br /> Application Accepted by Date - Anda 0 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: _ <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 BOX 2009, STOCKTON, CA 95201 <br /> IFEEO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. ` <br /> o EH 17.36(REV.ISNp) i � <br /> EH A-36 ••• KVIt:� <br />