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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> RECEIVE <br /> ENVIRONh[ENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 JUN 2 g 1999 <br /> (209) 468-3447 ENV'RONMENTAL 8EALTH <br /> j, DA <br /> EXPIRES 1 YEAR ORQ T UEb ISSI ERMIT/SII_ H <br /> (Complete la Triplicate) <br /> Application 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 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 City Lot Size/Acreage <br /> Owner's No r .r Address Phone <br /> Contract Address License No. 62___Phone a3-r;A*i ' <br /> TYPE OF WELL/?UMP: NEW WELL ❑ WELL REPLACEMENT'❑ DESTRUCTION ❑ Out of Service Well (❑ <br /> PUMP INSTALLATION W' SYSTEM REPAIR Cir OTHER ❑ Monitoring Well C7 <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 /> f7In trill ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing <br /> Public Specifications <br /> L7 I:7 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Gi Irrigation <br /> 1<—, pt!)Depth . �) Eastern r Surface Saul Installed by <br /> Repair Work Done W Type of Pump H.P. State Work Done y�v <br /> Well Destruction ❑ Wolf Diameter Sealing Material & Depth <br /> Depth . Filler Material A Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION L] REPAIR/ADDITION CI DESTRUCTION CI (No septic system permitted if public sewer is <br /> 1. <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) <br /> �_,.•_ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Ca cit <br /> Pa y No. Compartments <br /> PKC. TREATMENT PLT.C7 , <br /> Method of Disposal <br /> Distance to nearest: Well - Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation <br /> Property Line r <br /> SEEPAGE PITS ""'"'""�""""'"" "`"�" ' � � _-— _ <br /> l I Depth Sita Number��'` <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS p Property Lina <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: "f 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 /> 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 tM 1 rf all require ac <br /> ini tions, Complete drawing on reverse side. <br /> Signed ` <br /> Title: <br /> Date: <br /> F fi D PARTMENT USEONLY �} <br /> Application Accepted by i DatapC <br /> t Area <br /> Pit or Grout Inspection by Date Final Inspection by / <br /> D is 3 <br /> Additional Comments: <br /> Applicant - Return all copies to: — <br /> p SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN,-P O BOX 2008, 9TUCKTON, CA 852p1 <br /> EEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATI; <br /> n PERMIT'NO. <br /> . 1:H 17.711REV.tiw5t P2 <br /> EH 71.2e (� I r1 1Y{L j <br />