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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> REKNIT EXPIRES 1 YEAR IRON_ DATE ISSUED- <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 /> spplication 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 I3 3 -f�/�-��' _- --- --- - City Lot Site/Acreage <br /> Owner's NameONA41CA_ � �1/�� Address / 333 .��.1�2/u� Phone -a�� ~ <br /> Contractor ` t�� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ k OTHER D Monitoring.tiiell L7 <br /> =DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> LJJ J <br /> INTENDED USE "TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial �~ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casingi' <br /> L) Domestic/Private 0 Gravel Pack R`. ❑ Tracy Type of Casing Specifications Lf <br /> M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> G Irrioation a .Approx. Depth ❑ Eastern Surfice Seal Installed by <br /> Repair Work Done LJ Type of Pumpk H,P. State W rk Done— <br /> Watt Destruction Well Diameter' ZM 'i Sealing Material i Depth <br /> Depth _40Cl, Piller,: tatairial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,r.I REPAIR/ADDITION M DESTRUCTION ❑ INo septic system permitted if pubfic`aewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial: Other C4 I <br /> Number of living units: Number of bedrooms <br /> Character of *oil to a depth of 3 feet: Water table depth 5 <br /> SEPTIC TANK © Type/Mfg I Capacity No. Compartments T\, <br /> PKG. TREATMENT PLT, Ll Method of Disposal (' <br /> Distance to nearest: Well 5 Foundation Property Line <br /> LEACHING LINE Cl No. $ Length of lines Total length/size ' <br /> FILTER BED n Distance toenearest: Well Foundation,-, Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> t/ <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <br /> 1 hereby`cenify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state taws, and <br /> 1'1�irUlas 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'sueh manner as to become subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature <br /> certifies the following:."Tcartify 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." ti <br /> The appli nt cal all required inspections. Complete drawing on reverse side. . <br /> Signed Title: Dat/2L <br /> FO =T.USII ONLY _ _ <br /> Application Accepted by Date Qr� w / �` Area yr <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: .SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> "ENVIRONMENTAL HEALTH DIVISION -PERMIT/SERVICES- <br /> 445 <br /> IVISION -PERMIT/SERVICES445 N SAN JOAQUIN, P -O BOX 2009, STOCKTON, CA 95201 <br /> FEE)NFO AMOUNT DUE AMOUNT REMITTED* QKCXVR RECEIVED 8V. DATE PER 'NO. <br /> . Ehr i3.7�TREY.tinfli j <br />