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f APPLICATION FOR PERMIT i I <br /> SAN JOAQUIN COUNTY PUBLIC HE V I C <br /> ENVIRONMENTAL HEALTH D V � <br /> 445 N SAN JOAQUIN, PHONE ( 316-f-13420 H.P 0 BOX 2009, STOCKTON, �•�....�. l <br /> PERMIT EXPIRES 1 YEAR FR M <br /> (Complete in Tripli aM 7/75Application is hereby made to San Joaquin County for a permit to construct T is <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 andthe Rules an ego na o n <br /> Joaquin County Public He&llth Services. <br /> Job Address �" ;'� City L Lot Size/Acreage <br /> _Owner's Nemet _ 11M[�Idrs Address <br /> Phone <br /> a <br /> Contiaclor d bld <br /> .� Addres �- fj /t�-J �License No Phone <br /> .TYPE OF WELL/PUMP: NEW WELL ❑ :WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well n <br /> ?DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOf1NDATlON AGRICULTURE WELL _` OTHER WELL PITS/SUMPS <br /> INTENDED USE .,-TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Caiing <br /> �l Dome'sticlPflvals ❑ Grivel Pack:. ❑ Tracy . Type of Casing" Specifications <br /> I'I Public Cl Other n'Delta Depth of-Grout Seal Type of Grout ' <br /> I 1 Ifrivation•, Approx•-Depth I I Eastern Surface Saul Installed by <br /> Repair.Work Done U Type of Pump H.P, State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth bilker Material i Depth <br /> TYPE OF-SEPTIC WORK;=NEW-INS_TA- LATiON" ]fREP,AIR/ADDITION I 1 DESTRUCTION I i rlhlo septic system permitted if public sower is <br /> / available within 200 feet.) <br /> 'Installation will serve: Residence v Commercial cher <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fast: Water table depth <br /> SEPTIC TANK: ❑ Type/Mfg �- CapacityC2 CA� No. Compartments <br /> PKG. TREATMENT PLT.0 r-- Method of Disposal <br /> Distance'to nearest: Well . � Foundation �r' Pr � � <br /> operty Line <br /> LEACHING LINE No. fk Length of lines 3 '— Total:length/size <br /> FILTER BED Cl Distance to nearest: Well /4M __ FoundationsProperty Lina <br /> SEEPAGE PITS I I Depth Siie <br /> SUMPS Oistance to nearest: Well Foundation._Z2 P`^_ Properly.Line <br /> DISPOSAL PONDS 0 ­ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the Sen Joaquin County , <br /> Home owner or licensed agent's signature certifies the following: "I cenity 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 compe143ation 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 ail reqoirod intipections. Complete drawing on reverse side. <br /> Signed Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Data � Q' Area <br /> Pit or Grout inspection by date Final Inspection by � k w Date <br /> Additional Comments: <br /> Applicant,- Return all coples .toi San Joaquin.C,ounty Public Health Services <br /> Enbi,roame9tai Health Permit/ServicesZA - .. <br /> 445 N San'Joaquin, P 0 How 2009, Sthn, CA 95201 <br /> .FEE ' <br /> INFOir AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> . EN 13.24 MEV._,r n 51JW <br />