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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1f6 ` <br /> ENVIRONMENTAL HEALTH DIVISION tf 19 0 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 1992 <br /> P O BOX 2009, STOCKTON, CA 9520 B1'q i0AQL11lrf f,0U <br /> rt ' HEA1-TH SF UiCCS <br /> PEMIT EXPIRES 1 YE FR M D TE S ENTAL BASF-WIVjS{�n� <br /> (Complete in Triplicate) <br /> Application is hereby —4 to San Joaquin County for. a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Sem ui County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> Job Address <br /> � � 5City Lot Size/Acreage <br /> _ <br /> Owner's Name t + ddress ��7 -- Phone <br /> 1 � <br /> Contracllu_ _ _AddressPp License No. Phone <br /> 41�_w <br /> TYPE OF WELUPUMP: NEW WELL ❑ WELL REPLACEMENT 01-. DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR _1i OTHER ❑ Monitoring Well ❑ <br /> F <br /> DISTANCE TOINEARE5T:, SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> EI FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDEDSUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS; <br /> 0 Industrial R ❑ Open Bottom. D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing # Specifications <br /> Public 1_1 Other fl Delta ,Depth of Grout Seal Type of Grout <br /> li I Irrigation —.Approx. Depth I astern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. ^�?(3 State Work Done _KA AlMC+ <br /> Well Destruction ❑ Well Diamet tr Sealing Material i Depth <br /> I Depth t Filler Material i Depth <br /> TYPE OF SEPTIC WORK:k NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i lNo septic system permitted it public sower is <br /> t _ available within 200 feat.) <br /> Installation will serve: Residence— Commercial Other <br /> t <br /> Numbs of living units:if Number-of-bedrooms <br /> Character of$ON to a da6th of 3 fast: Water table depth <br /> SEPTIC TANK.` 9 I Type/Mfg s f Capacjli { No. Compartments <br /> PKG. TREATMENLPLT. 1 y �-----�'�- i Method of Disposal <br /> Ince to nearest: Well Foundatigin Property Line `� F <br /> LEACHING LIE Q No. b Length of lines Total length/size t <br /> FILTER BED ' �- ED Distance to nearest. Well Foundation Property Line r' <br /> SEEPAGE PITS> -''� 10 Depth Sue Number <br /> '`W i <br /> t <br /> SUMPS 101 Distance to rtaarest: Well .Foundation Property Lina <br /> DISPOSAL PONDS CI ` <br /> 1 hereby certify That I ha4prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ruiss and regulations of the San Joaquin county; 19 <br /> Home owner or�Iicenssd giant's iagnature certifies the following: I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any par in suchimennar as to become subject to workmaks compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fo 9I U."I cirtify that in the performance of the work fj r which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> tion laws R nla." s <br /> The spplica at call fot'all rsq Inspection. amplete drawing o v side- ? <br /> Signed - Title: Date: ' <br /> t f� <br /> FIOR ART USE ONLY <br /> Application Accepted by Data Area �f <br /> Pit or Grout Inspection by Date Final Inspection by da Data f t �✓ <br /> i <br /> Additional Com manb: 77 . <br /> Applicant: - Return all copies to: San Joaquin County Public Health Services <br /> fl Environmental Health Permit/Services <br /> 445 H San Joaquin, P Box 2009, Stkn, OA 95201 <br /> j <br /> FEE MOUNT DUE AMOUNT REMITTED K R YCEIVED BY ATE PERMIT'NO. <br /> I �j H <br /> EN 13.24(REV.I , s�S <br /> EN 1426 •J <br />