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APPLICATION FOR PERMIT <br /> SAN JOAQU;IN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> .•'�445"N. %SAN JOAQUIN PHONE (209)468-3420 <br /> P.Pr0 BOX 2009, STOCKTON, CA 95201 <br /> ERM T EXPIRES I ffF <br /> M FR- QM D TE <br /> 4. (Complete in Triplicate) <br /> Application is hereby made to Son Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made 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 /> Job Address �° .� s City Lot Size/Acreage <br /> � Y 4 <br /> w <br /> mma <br /> Owner's Na'' r Address _ W- <br /> ORe L�aL''• -<J •�i <br /> Contractor L��.y2 _Address .. <br /> License No. Phone>'; <br /> TYPE OF WE!!/PUMP: NEW WElL',--D- WELL REPLACEMENT ❑ DESTRUCTION D Out of Serg5Well ' <br /> i G.``' <br /> PUMP INSTALLATIOfV`❑ SYSTEM REPAIR OTHER Dy Motiitor <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE.FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSINTENDED USE TYPE OF WELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS11 Industrial Open Bottom p Manteca Dia. ofWell ExcavationflDomestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> n Tracy Typo of Casing_ Specificationsi"1 Public 1� Other nDelta Depth of Grout Seal I I Irrigation —.Approx. Depth I I Eastern TYPa of Grou , <br /> Surface Soul Installed by r w <br /> Repair Work Done U -Type of Pump H.P. �°� State Work Dona <br /> WOR Destruction 11. , 'Well Diameter Sealing Material i Depth , <br /> Depth.. Filler Material Z Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION�I I DESTRUCTION I I (No se- tics stem ti —r I <br /> ' P Y permitted i! public sewer is <br /> Installation will serve: Residents Commercial Other available within 200 feet.) <br /> O <br /> Number oilfvinp units: Number of-bedrooms F i <br /> Character of soil to @ depth of 3 feet. ' ,• `i <br /> SEPTIC TANK. Water-tibia depth <br /> ❑ Type/Mfg Capacity_,,,,;, No. Compartments <br /> PKG. TREATMENT PLT. ❑- '" - <br /> Method of Disposal ^ti. <br /> Distance to nearest:' Well Foundation Property Line *� <br /> LEACHING LINE C1 No, 6 Length of linea " <br /> FILTER BED Total length%aize <br /> 0 Distance to nearest: Well Foundation <br /> Property line <br /> SEEPAGE PITS 11 Depth Size l'*� ' <br /> Number tom, <br /> i SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ e Property Lina <br /> I hereby certify that I have prepared this application and thatthe work will be done in accordance with San Joaquin county ordinances, stat@ laws, and <br /> rules and regufatiorts 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 <br /> employ any person in such manner as to become subject permit is issued, f shall notct to workman's compensation laws of California."Contractor's <br /> certifies the following: hiring or subcontracting signature <br /> "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's eompensa <br /> .. tion laws of California." <br /> The applicant t call for I required in a <br /> eq apactions..Complets drawing on reveres side. ' <br /> Signed <br /> Title: Dat J� <br /> FOR DEPARTMENT SE ONLY <br /> Application Accepted by - <br /> Dais Area <br /> Pit or Grout maps Wn by Data <br /> Final Inspection b Data 1 <br /> Additional Comments: / <br /> Applicant - Return all copies to: San Joaquin County Public Health Services S ����• � <br /> Environmental Health permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95241 <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INFO CASH RECEIVED BY DATE PERMIT•N0. <br /> �H 4-24(REV.11 <br />