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APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> F ENVIRONMENTAL HEALTH DIVISION 1� <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 JAN 2 `w <br /> PST. IRTsB 1 YEAR told DATR ISSUED �ts Vt''v 'IVTAf <br /> (Complete in Triplicate) PEPA 1T/SCr VICES F<LTH <br /> Application Is hereby made to Sas Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application In zade-in coViiance 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 6 ...­ 01A=1A Lot Size/Acreage <br /> Owner's Name L:Lc..Q: Address Phone <br /> c <br /> IO— <br /> Contractor .Address 02 p�?ifense No._ �� c'/ <br /> Ahon54 <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT I`1 DESTRUCTION ❑ Out of Service well Ll <br /> PUMP INSTALLATION ... SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> ., SEWER LINES �____,,,`�,• DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> omastic/Private ❑ Gravel PacJ <br /> n Tracy. Type of Casing � <br /> M Public Specifications , n <br /> f:7 Other 0 Delta Depth of Grout Seal Type of Grout <br /> t'J lair Won ADepth d Eastern �,Surface Seal Installed by <br /> Repair Work Done Type of Pum <br /> p/�t H,p �Z- State Work Done �L- <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth Q <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION REPAIR/ADDITION M DESTRUCTION CI INo septic stem <br /> P Y permitted if public sewer is <br /> Installation will serve: Residence, Commercial_ Other available within 200 feet,} Jt <br /> Number of living units; Number of bedrooms U� <br /> Character Of soil to a depth of 3 feet; <br /> SEPTIC TANK. .. ❑ Type/Mfg f - Water table depth ` <br /> Capacity _r <br /> PKG. TREATMENT PLT.❑ r �• ' �''�- • <br /> No. Compartments <br /> k ,-4 _'. t Method of Disposal <br /> T71— Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines <br /> FILTER BED <br /> Notal length/size , } <br /> n Distance to n_ea►est—Will' `' Foundation. <br /> l Property Line y1LL <br /> SEEPAGE PETS 11 Depth I Size C <br /> SUMPS Number <br /> LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ 1 mak,. 1• t. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wiftl 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 subcontracting signature <br /> certifies the following; "I certify that in the perlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion laws of California." t <br /> The applicant m III/or all required 'inspections. Complete drawing on reverse side. <br /> Signed Title: _ -•--� <br /> - - .. Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> S Area <br /> Pit or Grout Inspection by Date <br /> Fina! Inspection by Data / 9 <br /> Additional Comments: <br /> Applicant - Retura ail copies to: t <br /> P SAN JOAR UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQU;N.,.,P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> r EH 13•I4 tfIEV.it s i Ld-- ___it =Y�_= <br /> M h <br /> �1 <br />