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APPLICATION FOR PERMIT <br /> '_ l 1p �ab <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR PRA RATE-ISSUM <br /> (Complete in Triplicate) <br /> Application 1s 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 2&rZ AUE - City ' . Lot Site/Acreage <br /> LAI 7 9Q Phone <br /> Owner's Name T Address <br /> Contractor " _�N `� Address License No. ys��7a Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well. ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> i U Domestic/Private C) Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> - <br /> M Irrigation _ _.Approx, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br />` Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK:, NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION FJINo septic system permitted if public sewer is <br /> /aavailable within 200 feet.) <br /> Installation will serve: Residence. Commercial. //Othir <br /> Number o1 living units: Number of bsdrpoms',. <br /> Character of soil to a depth of 3 feet: /V y Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 21 Capacity 4 _ No.:Compartments <br /> z <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well A0 Foundation,` ` A0 Property Line ?�•� <br /> LEACHING LINE @4. No. & Length of lines 2 Tpl lengthIsis* <br /> i <br /> f1LTER BED n Distance to nearest: Walt Foundation /6kf) Propeny line <br /> SEEPAGE PITS 11 Depth SiZeNumber <br /> SUMPS A Distance to nearest: Welf 160 foundation Property Line Zo! <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 or'dinancas, state laws, and <br /> rules and regulations of the San Joaquin County is ` <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 t <br /> t! employ any person in such manner as to tiacome 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 parsons subject to workman's compensa- <br /> tion laws of California." t <br /> The applicant must call for all required in"plions. Complete drawing on reverse side. <br /> Signed •o-"`-CL Title: Date: . <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by r C c -- _ Date Area <br /> f Pit or Grout Inspection by Date Final Inspection Dater o <br /> Additi�o'D�1 om nts: /j,�rlfJ .�F/�' <br /> App 1] an � 744 �opias oi� A JOAq N�COUNTYP PUBLIC HEALTH 9E'itVICE `�'c/ �✓ � o�,�%!�i6�rfi/� .� <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> ' 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> j. <br /> EEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED 9Y DATE PERMIT-No. <br /> INFO 1 CASH <br /> . tiH 13-24(REV.iIAs) <br /> EH',4.n 1 <br />