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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 9MIXi 9MIA95- X YEAR FROM DATE ll—a= <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 /> M40 application is de in cottlpliance 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 Pr JA (e h 4 +rP• City Lot Size/Acreage <br /> Owner's NameWA L[OIV �l�/ � D 0 w o�, Address _�� � � �~��t�� � k r ' Phone a-d � 1 <br /> Contractor__!Ze (if;!— Address A d P t PV01(t0 %AP4 • License No. Phone 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing - �^ <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a <br /> M Public EI Other p Delta Depth of Grout Seal Type of Grout <br /> CI Irrigation �.ApprcK, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H,P. State Work Done_ <br /> Will Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Filler Materiel i Depth ; I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION. (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: 6 f Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: -Well Foundation Property Line f ` <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 11 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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." -F - <br /> The applicant <br /> must <br /> �ca for all <br /> rrequir in pact' Complete drawing on reverse side. <br /> Signed Yt/M 4" - y"9 Title: <br /> Date: o — 1 S- <br /> 90 <br /> — n <br /> DEPARTMENT USE ONLY 4 <br /> Application Accepted by Date Araa <br /> Pit or Grout Inspection by Dat Final Inspection byDate:F4a <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 O BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . EHU•24fREV.iiKsl <br /> Ek;1.26 <br />