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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C� A� <br /> ENVIRONMENTAL HEALTH DIVISION l� <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 4 P 0 BOX 2009, STOCKTON, CA 95201 �aY <br /> PERMIT EXPIRES I Y AR FROM DATE S <br /> (Complete in Triplicate). <br /> Application is hereby made.to San Joaquin County for a permit to construct end/or install the work herein described. This <br /> application is grade 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 /> i! PLQ City Lot Size/Acreage <br /> Jab Address vv11Q' <br /> II 9 �`� Address [!' Phone IV <br /> "�A <br /> v Owner's Name ,p y e3_1 y 4 8 <br /> Contratta Address / L'+cense No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> SYSTEM REPAIR O"ER <br /> �nito�ing well <br /> PUMP INSTALLATION C3 .._r1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. E <br /> p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� <br /> C7 Industrial I Open Bottom ❑ Manteca Dia. of Well Excavation�{ Dia. i f Well Casing <br /> T of Casio �` Gl►► k/1J.vr?+ <br /> e _ Specifications. <br /> (-] Domestic/Private C1 Gravel Peck ❑ Tracy Type 9 - - - -- <br /> i'i Public Cl Other FA Delta Depth of Grout Seal :Ul Typo of Grout iel re14 <br /> t� Irrigation •12L Approx. Depth I I Eastern Surface Seal Installed by / <br /> Repair Work pone C] Type of Pump ;.nKnvr�__ H.P. State Work Done f eQd <br /> Wall Destruction ❑ Well Diameter Sealing Material i4 Depth _ un Kr10 oI�SCItttR��. <br /> II <br /> Depth Filler Material A Depth rE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION 11 (No septic system permitted if public sower is <br /> availabie,within 200 feet.) <br /> �l Installation will serve: Residence— Commercial— Other " <br /> Number of living units: Number of bedrooms ~. <br /> II Character of soil to•depth of 3 fest: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance.to n6arest: Well Foundation Prop6Ry'Lir <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size /J <br /> FILTER BED. ❑ Distance to rarest: Well Foundation Property Line <br /> v <br /> SEEPAGE PITS _ .'1 I. Depth Size Number <br /> f � <br /> SUMPS Ll Distance to rteanst: 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 Sen 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 /> dertifies 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." t. <br /> The applicant mut call for all requir inspections. Complete drawing on reverse sidlj <br /> 7- 2 3� 9� <br /> Signed Title: Date: T._ <br /> J� J Oft DEPARTMENT USE ONLY <br /> IS t <br /> Application Accepted by .,AA Date—_1 n 3-9�.._. Area <br /> I Pit or Grout Inspection by Date Final inspection by Date <br /> Additional Comments: <br /> ii Applicant - Return all copies to: San oaquin County Public Health Services <br /> 1 Environmental Health Permit/Services <br /> , 445 N San Joaquin, P O Bax 2009, Stkn, GA 95201 <br /> } FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE 1 PERMIT'NO. <br /> INFO I� <br /> . EH 15-14IAEV.1/ns1 r . [ <br /> EH 14-Ta <br />