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t <br /> of APPLICATION FOR PERMIT <br />� e <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3441 <br /> �r PTRHIT URIBE$I YEAR r9QX_PATE ISSUED <br /> (Complete in Triplicate) <br /> Applicailon is hereby made,to San'Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ccmpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. r <br /> I <br /> Job Address 60� City Lot Size/Acreage <br /> M PRI 1V14 <br /> Owner's Name �HI1DfS ` Address Phona � r <br /> Corttractor r Aftess ^!V'!t/���L' Lieensf O)a644:.?Phon• <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE'TO NEAREST: SEPTIC TANK SEWErR LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL"' OTHER WELL PITS/SUMPS _.. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial ❑ Open Bottom ❑ Manteca ! Dia. of Well Excavation Dia. of Well Casing <br /> LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> • M Public lel Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation ,_,,,..Approx, Depth ❑ Eastern { Surface Sedl Installed by <br /> ,\ Repair Work Done „L] Type of Pump, H.P. State Work Done <br /> Well Destruction ❑ Well Diameters. Sealing Material i Depth <br /> i� — =Depth t - „ ,Fiiler Material &,Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIR/ADDITION DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve; Residence_:. CommerciafOther <br /> Number of living units; ­42— Number of-bedrooms Tom_ f n <br /> -+ Character of soil to a depth of 3 feet: Water table depth- r M ti l� <br /> SEPTIC TANK ❑ Type/Mfg 4'- Capacity No. Compartments <br /> PKG. TREATMENT PLT,,K EXJ-6- r/ki3 Method of Disposal r <br /> " Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No. 8 Length of lines Total length/size <br /> FILTER BED f:1 Distsnee 1!0 nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth { Sue 4 Number <br /> SUMPS LI Distance to:nearest: Wolf Foundation Property Line <br /> DISPOSAL PONDS ❑ \ I / - ` <br /> I hereby certify that I have prepared this Fpplication 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 a <br /> Home owner or licensed agent's signaturaicomifies 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-bacome subject to workman"s compensation laws of Cafiforriia." Contractor's hiring or sub-contracting signature T <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." „ . <br /> The applicant must call for all req red spactions. Compl to drawing on reverse side.. <br /> SignedTit1o:���? Y . _ Date: 7/ <br /> :��r { • �FORARTMENT USE ONLY 1 , # i7 i S q L�-- <br /> Application Accepted by Date Area'—T <br /> E x.�- r w s Ifed:gaer� . <br /> Pit or Grout Inspection by Date Final Inspection by•.b4a fff/ f _ Date <br /> Additional Comments; <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � � <br /> f t ': ENVIRONMENTAL HEALTH DIVISION PEEWIT/SERVICES :Olt <br /> ' 1445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201FEE <br /> ® 517 93 <br /> INFO AMOUNT DUE , AMOUNT REMITTED CASH RECEIVED BY DATE <br /> PERMIT No. <br /> . E„1`.�111EY.iie61 rrS7 0111 Sd t7 <br /> S-1 <br />