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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> BOX 2009, STOCKTON, CA 95201 <br /> } ` (209) 468--3447 <br /> PEUIT E.XT,IRB,S _I7EAE T ROM DATE ISSUED <br /> a r (Complete in Triplicate) <br /> I Application In hereby made to Sam Joaquin County for a permit to conatruct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 5h9 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> F j 4 <br /> Job Address Z i CiryLot Size/Acreage <br /> Owner's NameAddress! <br /> Contract ! Address, _--, -icense Nczsi6�- Pho <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION G Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Fj' <br /> -C <br /> f_7 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U DomesticlPrivate Ll Gravel Pack ❑ Tracy Type of Casing ' Specifications <br /> r M Public I'1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done <br /> r Wait Destruction O Well Diameter Sealing Material 4 Depth <br /> ' Depth Filler.Material i Depth <br /> 4F TYPE OF SEPTIC WORK: NEW INSTAL LAVON 0 REPAIR IADDITIONX DESTRUCTION lNo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> I Installation will serve: Residence Commercial Other <br /> Number of living units: J_ Number of bedrooms •- - ��-�—�--�C :�' <br /> I <br /> Character of soil to a depth of 3 feet: ��� .� ,/��(�( � Water table depth <br /> SEPTIC TANK. Typa/Mtg IEEE _L Capacity. No. Compartments <br /> I PKG.'TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I� LEACHING LINE y� No. & Length of lines �,` !x'� 9 �-�"- ��� Total length/size � <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ZO <br /> SEEPAGE PITS I I Depth -Size _ " <br /> ire ����Nu��mber' <br /> SUMPS Y-Distance to nearest: Well �7 Foundation �LL� 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 fallowing: "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: "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 must call for all require r n tions. Compola drawing on reverse side. <br /> Signeyy J <br /> tl -cam' R— Title ,...._.,_ Date: f�` <br /> ARTMENT USE ONLY yy <br /> Application Accepted by � Gya_ Qt= <br /> Dace I Area <br /> r <br /> Pit 4r Grout inspection by Date Final Inspection by' -5a' Date <br /> FAddit/lona! Common s✓r - i ,/ �� - -� <br /> App c t - urn etea OI <br /> A COUNTY P_11BLI H8 TH 8ES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICER <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 <br /> FEE INFO AMOiUNjT DUE AMOUNT REMITTED C K If RECEIVED BY DATE PERMIT NO.F <br /> EEH li t' fREY.rinSf 1 L 1 Q4 • 00 omitE� L�J <br />