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APPLICATION FOR PERMIT 4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES + <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> S <br /> Yr" DATE LWIM <br /> ' <br /> (Complete in Triplicate) r_ ' <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vorX heereinrdes rib d This ! <br /> application is made in cotWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> Vic- <br /> Job AddressCity <br /> r Lot Size/Acreage <br /> 7 'Id <br /> Owner's Name ! ��`� __— Address Gt1l Phone <br /> hJ /S6A��5 Address 94 / 5hW1�S1e/ fx Z 7-3 Phone <br /> • Contsactar _ License No. <br /> TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well .C1 <br /> PUMP INSTALLATION 9;--- SYSTEM REPAIR 13)-� OTHER ❑ Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PtTS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial - ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing <br /> omestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i <br /> G Irrigation — Approx. Depth Q Easternurface Seal Installed by <br /> Repair Work Done Type of Pump ,z H.P. State Work Done_ lctel_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> , I <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Cl DESTRUCTION GI (No septic system permitted if public sewer is <br /> available within 200 feet.} <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.C] Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <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 pers u ,nor <br /> as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the owing: , ce 'fy that in tha partofmanc f the work for which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws t Californls." <br /> The ap lice u t C 1"8,11 r u' o on r ide. r <br /> Sign s4 Title: Date: <br /> OR EPARTMENT USE ONLY Application Accepted by Date " L Area <br /> Pit or Grout inspection by Date Final Inspection by Date l5 <br /> x 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 2008, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO I CASH <br /> • EH13-24(REY.riN51 �{ 67a <br /> EH 94.78 «<✓✓✓Q..� "" Gam, V <br />