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APPLICATION FOR PERMIT <br /> MR�I+I COUNTY PUBLIC aEALTH SERVICES <br /> 4RONiI NIAL HEALTH DIVISION <br /> IQ l lQr.)2009, STOCKTON, CA 95201 <br /> S E P 0 8 1992 (209) 4683447 <br /> i <br /> SAKI JO I <br /> PUBLIC HEALTIhj S[:R4.6-inplete in Triplicate) <br />` <br /> Application is here atEade It�o�'I� � �,�'MEk' .TH I�'iS#0 <br /> pp by Joaquin �oun fora Permit to construct and/or install the work herein described. This <br /> application is made in eotapliance vith San Joaquin County Ordinance No. 549 end 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ^� City Lot Size/Acreage <br /> Owner's Name �. � Address __ Phone <br /> 1-7 <br /> Contrac —_=_ __ �Z�rAkddres � nse VZ. 01:2!-2—Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION S--' SYSTEM REPAIR 9--_ OTHER O Monitoring Well [1 <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 /> nInd T ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omastie/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Il Other 1 0 Delta Depth of Grout Seal t Type of Grout <br /> 0 Irrigation � Approx.,Depth C] Eastern Surface Seat installed by <br /> Repair Work Done i� Type of Pump H.P. '2� Stats Work Done O� <br /> Well Destruction 0 " Walt Diameter; Sealing Material i Depth <br /> it DeRth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADOITION 0 DESTRUCTION CI.INo 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 i <br /> Character of'soil to a depth of 3 feet: Water table depth x <br /> 4 <br /> SEPTIC TANK O Type/Mfg• Capacity No. Compartments <br /> PKG. TREATMENT_PLT,_❑ _ ., Method of Disposal <br /> Distance to nearest: Wel Foundation �_ �'"""�Property Line <br /> LEACHING LINE L'1 No. i Length of line' �' ' Total length/size <br /> FILTER BED Q Distance to nearest: Well Foundation Property Line ice? <br /> t . <br /> SEEPAGE PITS 11 Depth Size Number 4 <br /> SUMPS LI Distance tc nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies 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 fol which this mil is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of California." <br /> The applicant mu �allrequ�iredins Complete drawing on rev se side. <br /> Signed X Title: , <br /> 4-- Date: —r Z <br /> i <br /> FOR DEPARTMENT USE ONLY Gt, <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date Final Inspection by Date /O��7q <br /> Additional Comments: <br /> Applicant - Return all copies to: ]SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> iENTVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES " <br /> 1445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 65201 <br /> FEE AMOUNT DUE AMQUNT REMITTED e' Ct( RECEIVED BY DATE PERMI7'NO. <br /> INFO i <br /> . Ek 1721 IREV,tine �� �� _ ®ZT <br /> EM°x•20 t7 7 <br />