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APPLICATION FOR PERMITL <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONXENTAL HEALTH DIVISION ��`� �ow <br /> t" <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 Q <br /> _PERMIT EXPIRES 1 YEAR_FRQM DATE ISSUED � - <br /> (Complete in Triplicate) <br /> Application is hereby made to S" Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is smde in costplianceivith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. n )arc <br /> }Job Address A-Y-R City �lZ• � "s'1 Lot Size/Acreage <br /> Owner's Name 31±2YC5� St-C:L_1-Address R? k K b l S Phone <br /> Contractor _ 404,P1't 9 3 Address __ __S C License No. Phone S e- <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well (3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing f <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'1 Public Cl Other I f1 Delta Depth of Grout Seal . Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction , ❑ Well Diameter Sealing Material i Depth ' <br /> Depth ]tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is p <br /> available within 200 feet.) <br /> Installation will serve: Residence T Commercial_ Other `r <br /> Number of living units: Number of bedrooms <br /> Character of sod to a 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 nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. a Length of linea <br /> Total length/size <br /> FILTER BED ❑ Distance tolnearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth 1 Size Number <br /> SUMPS LI Distance to'nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 iignature cartifies 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." Contractors 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." <br /> The nt must call fo iced inspe s. Complete drawing on reverse side. <br /> SSignedTitle: Y _ Date: 2- 7-?2- <br /> , <br /> FOR DEPARTMENT USE ONLY• A <br /> Application Accepted by -- �'R ,Lyna Date Area <br /> Pit or Grout inspection by Date Final Inspection by / Data <br /> Additional Comments: z . <br /> Applicant - Return all copleB to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> . EN 13.241Inv.r,K 5) 7y, 7 LI, <br /> Ia <br /> EH �• pL <br />