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r - APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 4 ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> 21 <br /> Y R <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application Is made in eoWliancc 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 ` �" f -�' •r�'�, ��� '"-� - —•--- City Lot Size/Acreage ,� •-_ <br /> Owner's NameAddress �, �� "' � Phone <br /> Contractor �E4-1F `Address 301 '] 'Qc =Q-L'lV -license No. Phone�`'�35�o`fa6 <br /> ,TYPE OF WELL/PUMP: NEW WE>='LWELL REPLACEMENT Cl_ DESTRUCTION Ll Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TA.N& SEWER LINES DISPOSAL FLD. ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL r PROBLEM A1141.9k CONSTRUCTION SPECT IONS <br /> f7I Industrie! ❑ Open Bottom ❑ Manteca f Well E ion Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack j. _❑ Tracy Type Specifications <br /> Z1 Public 1'1 Others -0 Su <br /> Delta epth of Grout _ Type of Grout (� <br /> CJ Irrigation -` 4 , __ Approx. Depth 0 Easte Surface Soul Installed,by Q <br /> t Repair Work Done U Type of.Pump H.P. State Wo no — <br /> I; Well Destructions ❑ Well Diameter Sealing Material i Depth <br /> Depth <br /> F ' Filler Material dr Depth j,' <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Ll DESTRUCTION F-I lNo septic system permitted if public sewer is <br /> + available within 200 feet.) / <br /> Installation will serve:- Residents Commercial_ Other ., • <br /> f Number of living units: Number of, edrooms ) <br /> Character of soil to a depth o!3 feel: Water table depth , <br /> SEPTIC TANK. - ❑ Type/Mfg Capacity 1-04 No. Compartments <br /> PKG. TREATMENT PLT. Cla t � .� Method of Disposal <br /> t.. <br />+ Distance to nearest: W �ell oundatiori Y Property Line <br /> LEACHING LINE I'_No. & Length of lines IF Total length/size-Z, 0C) <br /> FILTER BED n Distance to nearest: Well Foundation" Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS 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 <br /> certifies the following: "l certify that in the performance of the work for which this permit irissued, I shall employ persons subject to workman's compensa- <br /> `tion laws of California." <br /> I Thea applicant mu o all required inspections. Complete drawingon reverse side. <br /> PP q <br /> /Pigned X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 0 � Dated Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> r <br /> Additional Comments: %2 a,7:4__A,41j.;, <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> f 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 65201 <br /> FEE Ilk INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> ffff EFHIk3.mIREV.r/nsi lly 66 I It-A � V-1 11 t I -N -Wio <br />