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co <br /> APPLICATION FOR PERMIT { <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,9 1­�) � <br /> ENVIR0NMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIREB 1 YE FROM D TE ISSUED <br /> (Complete in Triplicate) <br /> t <br /> Application is here#lry made to Sea Josquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of <br /> Joaquin County Public Health Services. San .. <br /> Job Address Q <br /> Cit Lot Size/Acreage <br /> NameOwnei's Nam <br /> r. Address <br /> Phone <br /> f--� <br /> t . TYPE OF WELL/PUMP: ansa �' 'Phone <br /> ' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out or Service Well C) <br /> PUMP INSTALLATION 4Zt-----"" SYSTEM REPAIR O OTHER ❑ 140nitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES - DISPOSAL FLD. .PROP. LINE <br /> N <br /> FOUNDATIOAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ In ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> lst'Uomestic/Private ❑ Gravel PackDia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> Il 1 Publie ll Other Specifications <br /> Cl Delia Depth of Grout Seal <br /> I I Irrigation I Type of Grout <br /> Fh -Approx. Depth I I.Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pum �.�. <br /> Well Destruction ❑ Well Diameter Sealing 14aterial-i-Depth-, State Work Done <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION & I DESTRUCTION l t (No se tics stem permitted if public sewer is <br /> P y (� <br /> " Installation will serve: -Residence` Commercial available within 200 feet.) <br /> Other` <br /> Number'of Vving units: Number of bedrooms _ <br /> 'Characiar of Solt to a depth of 3 feet: <br /> F SEPTIC TANK. ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT.❑ Capacity _ NO. Compartments , <br /> Method of Disposal <br /> Distance to nearest: Well Foundation_ <br /> Property Line <br /> LEACHING LINE ❑ No. ✓y Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> length/size f <br /> Foundation Property Line <br /> F' SEEPAGE PITS I I Depth Size <br /> SUMPSNumber <br /> CI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ ------ Prape►tY Lina <br /> F' I hereby certify that 1 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 canifies the following: "{ certify that in the performance of the work for which this ; <br /> employ any person in such manner as to become subject to workmen's-comp ensalion laws of California."Contractor s hiring osub-contracting lsignaltn not <br /> unifies the following: "I certify that in the performance of the work far which thin <br /> Non laws of California," permit is issued, I shatl employ persona subject to workman's compensa• <br /> The applicant must 1 required i tions. Complete drawing on re as side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT 11SE ONLY <br /> Application Accepted by , <br /> Date Area <br /> Data <br /> Pit or Grout Inspection by cl <br /> ---�� Final Inspection ,� 3 <br /> Additional Comments: by Date <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> fff Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFp` C H RECEIVED BY DATE h <br /> PERMIT NO. <br />-. <br /> 13-24 J� q�- - Q_ 36 f7 <br /> �- _7_9 93 �� y 3 <br />