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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE SU <br /> (Complete in 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 coWliance 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 /CK-0 Ar 'X�l;4 A!� 0__ City S' Lot Size/Acreage pZ,2,4CPe< <br /> Owner's Nama y~ tLAddress iA Phone <br /> Contractor r ( r ZliCAddress JZ! License N ��� 21- Phon. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN L><_ DESTRUCTION' t of Service Well ❑ i <br /> PUMP INSTALLATION ❑ , SYSTEM REPAIIj C] OTHER C) Monitoring Well n <br /> II 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �/20 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r.� <br /> L) Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation pia. of Well Casing <br /> X-09mestie/Private ravel Pack7 ❑ Tracy Type of Casing_ PSpecifications <br /> I"1 Ptrolic heri �p �l Delta Depth of Grout Seal Y/?B r Ty rof Grout _ <br /> I I Irr anon A� o Depth l I Eastern Surface Seal Installed b &d2 ��171 !�.r a* f rt S' <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction bil Well Diameter Sealing Material i Depth [ a <br /> Depth 7 / .Ok Filler Material i Depth �\t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is <br /> ... available within 200 feat.! <br /> Installation will serve: Residence^ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil 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 Cl No. & Length of lines Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS f_° I LI Distance to nearest: Well Foundation Property Line <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 ordinances, state laws, and ' <br /> rules and regulations 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 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 a <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 required inspections. Complete drawing on reverse side. <br /> Signed X �L �-tI�:N _._. Title: 1Jr Dats `7d��'9� <br /> FO EMIT USE ONLY <br /> Application Accepted by Date Area O?Z�c <br /> Pit rout nspection by Das Final Inspection by Date <br /> Additlonaf Comments: {/ r � �' •� <br /> c <br /> Applicant - Retur all copies to: San Joaquin County Public Health Services c <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin Box 2009, Stkn, CA 95201 <br /> i # <br /> FE AM UNT UE AMOUNT REMITTED RE EIVED BY D TE PERMIT'ND. <br /> lI,N�F <br /> • EH 1}21(REV.1),a 51 <br /> EH 11-9a 490 - Z2 <br />�-_- <br />