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APPLICATION FOR PERIdIT RE gat, VE D�� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES > <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 ENV1P�SUN 2 8 1991 <br /> (209) 468--3447 MENTAL. HEALTH <br /> D F <br /> SIEXIRS 1 YE <br /> T PE _ AR ROM DATE ISSUE �[1' MI VIC <br /> T1SCPF <br /> hF a <br /> (Complete in Triplicate) <br /> Application is hereby made•to Sau Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ccawliancelvith San Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> e�L <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Address <br /> Phone {; <br /> Conte acto Address 3 D <br /> License N 01 14101 — Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT `❑ DESTRUCTION 0 Dut of Service Well ❑ <br /> PUMP INSTALLATION . SYSTEM REPAIR 43 OTHER p Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r a DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Oo astic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> W'Publicc I'1 Other ❑ Delta Depth of Grout Seal Type of Grout ` <br /> M Irrigation Approx. Depth 0 Eastern Surface Seal Installed by ^� ` <br /> Repair Work Done .E3 Type of Pump is r4.�--- KP. State Work Done <br /> Well Destruction O Well Diameter 1 Sealing Material is Depth / r J <br /> Depth 1. Filler Material i Depth Vr� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION Irl DESTRUCTION G (No septic system permitted if public sewer is <br /> Installation will serve: Residence�6iCommercial - Other - available within 200 feet.) r.J <br /> Number of living units: Number of bedrooms- } r <br /> Character of gait to a depth-of 3 feet <br /> Water table depth <br /> SEPTIC TANk- ' El Typi/Mfg Ca <br /> No. Compartments <br /> , <br /> -r ,. �� PacitY�,,. <br /> PKG. TREATMENT,PLTr. [1_ Disposal <br /> " "" Method of Di <br /> Distance to nearest: Well Foundation Prbperty Line <br /> LEACNi NG LINE L1 No. 8 Length of lines Total length/size' <br /> FILTER BED n Distance-to nearest:-- Well - -� 'Foundation- - t s <br /> .) ,Property Line ` <br /> SEEPAGE PITS 11 Depth "I Sire " ' A Number t <br /> SUMPS \LI 'Distance tayriearest: <br /> DISPOSAL PONDS ❑ ,J Well Foundation Property Line <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 person in such manner as to bedome subject to workman's compensaiionuaws 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 shat)employ persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant all or all requirgid inspections. Complete drawing on reverse side: <br /> Signed Title, Date: G.--1 IV i <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Dateoff/ DC7 { <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by --�� <br /> Data / <br /> Additional Comments k <br /> Applicant - Return all copies to: jl Q <br /> P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC$S <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE j AMOUNT REMITTED j' <br /> INFO <br /> � t CASH —RECEIVED BY DATE PERMIT NO. <br /> + Ek1721IRrsV,kirsi /� � �� <br /> Ek;1•ZE I ! `"� <br />