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4 y APPLICATION FOR PERMIT <br /> $A .%QUIN COUNTY PUBLIC HEALTH SERVICES <br /> REC:EIVEV3IVIRONMENTAL HEALTH DIVISION <br /> sEP O apl ffOX 2009, STOCKTON, CA 95201 <br /> SAN JOAQUIN COUNTY (209) 468-3447 <br /> PUBLIC HEALTigMIMATFIEX 3AR kBOAt DATE ISSUER <br /> ENV)RONN"ENTAL HEAL1'H DIVIS('4,pmp1ete in Triplicate) <br /> Application is hereby made,to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ceetpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin CountyPublicHealth ServicesT <br /> Job Address L r-24 City2= •Lot Size/Acreage <br /> Owner's Narnei1��.[.e-� L� _..— Addrsss � (� ~ { One <br /> r <br /> Conttac Addte ense Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ / WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well C) <br /> PUMP INSTALLATION ;00_ SYSTEM REPAIR ❑ OTHER Q Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD,— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> MI nd iol El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public I:1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M irrigation Approx. Depth ❑ Easternuriace Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. `fes State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK:: NEW INSTALLATION LD REPAIR/ADDITION 0 DESTRUCTION Gi lNo septic system permitted if public sewer is <br /> available within 200 feet.} <br /> Installation will serve: Residence^ Commercial_ Other <br /> Number of living unlit: Number of bedrooms Q <br /> Character of *oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. A Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS IJ Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify 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 becoms subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <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 m all required iAppfq2aE Complete drawing o arse side. <br /> Signed Title: Date: _1 3 4 �Z- <br /> F,OR DEPARTMENT USE ONLY <br /> Application Accepted by Date CPO/aq7__ roe / <br /> Pit or Grout Inspection by Date Final Inspection by- Date <br /> Additional Comments: _ <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BO% 2409, STOCKTON, CA 95201 <br /> INFO /FEE AMOUNT DUE AMOUNT REMITTED e�CK RECEIVED BY DATE QPERMIT'NO. <br /> . Eft t]•7�IltEV. i n al ; "' <br /> `'C� �b il-; �� J 13( C.rt1 <br /> E3+;�•2a <br />