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I i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQTJIN COUNTY PUBLIC HEALTH SERVICES <br /> ,ENVIRONMENTAL HEALTH DIVISION � <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 4.68-3447 <br /> (Complete in Triplicate) <br /> Application is hereby made.to San+'Joaquin county for &-permit to construct and/or install the vork herein described. This <br /> application in made in compliance vith San Joaquin County Ordinsneo Po. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> + �� Lot Site/Aet'e:age <br /> 9yu��. <br /> Job AdAddressf l�"'��' � _��( <br /> 4 Owner's Name +" n flJ u �n Address _ Phone 77r! <br /> Colthact6r Address 35 <br /> License N034qo,7?—P e'/. <br /> NEW WELL ❑ WELL REPLACEMENT I"] DESTRUCTION t of Service Well ❑ <br /> TYPE OF WELLlPUMP: . OTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION ❑ . SYSTEM REPAIR I7 <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PiT515UMP5 <br /> FOUNDATION r�.—=AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ..+ <br /> Dia. of Well Casing <br /> 0 Industrial C7 Open Bottom D Manteca Dia. of Wail Eltcavalion Specifications <br /> G]-Domestic IPrivate Ci Gravel Peck C!Tracy. Type of Casing <br /> ID Public I:1 Other ❑ Delta Oeptt of Grout Seal Type of Grout„ _J <br /> t'J Irlioslion —.Apmor' Depth ❑ Esatairt Siirfpace Soul Installed by <br /> T Repair Work Done V "Type of Pump H.P. State Work Done �v0 <br /> �`' Sealing material i Depth t[[ <br /> f Well Destruction Well Diameter �� <br /> peplh Filler Material * Depth u F� ,7a_ Int <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 13 RE0AIRlADD1TION 0 DESTRUCTION G (No septic system permitted if public sewer is It r <br /> available within 200 foot.) <br /> installation will serve:- Residence — Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Characlo of soil to a depth of 3 feet: Water table depth <br /> �• Capacity No. Compartments <br /> SEPTIC TANK., ❑ Type/Mfg""' <br /> PKG. TREATMENT.PLT.D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE f C1 No. 6 Length of lines Total lengthlsize <br /> s <br /> FILTER BED Cl Distance to dearest: Welf Foundation Propsny Lina <br /> SEEPAGE PITS i I Depth t Sire Number <br /> SUMPS } LI bislance to nearest: Well Foundation Property Lina <br /> r• DISPOSAL PONDS O + <br /> I hereby cenify that I hove prepared this application and that the work will bo done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Homo owner or licensed agent's signature certilies the following: "t certify that in the performance of the work for which this permit is issued. I strait not <br /> employ any person in such manner as to become subject to workman's compensation laws of CoVornia."Contractor's hiring or sub-contracting signature <br /> cenifies the following: 111 certify that in the performance of the work for which this permit is issued,I shall ernpioy persons subject to work man's compansa- <br /> tion laws of Caiifornls." t <br /> The applican m all for puired inspections. Complete drawing on reverse side: �— <br /> 4 <br /> Signed - Title: Data: <br /> R`DEPARTMENY USE ONLY <br /> Application Accepted by Date 3— Area <br /> Pit or Grout Inapection by Data <br /> Final Inspection by Date?3� <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 H SAN JOAQUIN, P O SOX 2008, STOCKTON, CA 65201 <br /> FEE AMOUNT DUE AMOUNT REMITTED LASH RECEIVER By DATE PEAMITNO. <br /> INFO _ �q .. / .�/� <br /> . EH1}7/1AEV.IfMsl E,1fO r ®� // �-�_ / �R7 .l Z �r3 nV 6 <br /> EM t{•2a V ( - <br />