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APPLICATION FOR PERMI <br /> i SAN JOAQUIN COUNTY PUBLIC HFALT Qft*C_ _ >-_---"- <br /> I ENVIRONMENTAL HEALTH DIVI ION <br /> T <br /> 445 N SAN JOAQUIN, PHONE (209) <br /> R ' P O BOX 2009, STOCSTON, CA A0 <br /> fJ <br /> - PERMIT MWIRES FROM D Q! �� <br /> � (Complete in Triplicate <br /> Application is hereby made,to flan Joaquin County for a permit to construct and/or install the work herein described. This <br /> application In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and tpe Rules and Regulations of San <br /> r P <br /> Joaquin County Public Health Services. <br /> Job Address Q ° `^ Cityl Lot Size/Acreage <br /> `/ <br /> Owner's Name Address dt �- .542 T499�-"` f Phone <br /> Contractor AddressP 'C '/!C _%1 G i't,/1� License No d Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Seryice Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS: # <br /> *I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bonorn 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FJ 11 Pubtic F. 1 Other fl Delta Depth of Grout,Seal Type of Grout <br /> Irrigation __Approx. Depth [A Eastern Surface Seal Installed by <br /> Repair Work DoneP Type of Pump ^�[l �"H,P. �� State Work Done �•� •. <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> ' Depth Filler Material t Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is V`I <br /> r <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sop to a depth of 3 fen: Water table depth ' <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.LineF. h <br /> # LEACHING LINE ❑ No. 8 Length of lines Total length/slre <br /> FILTER BED Q Distance to clearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number " <br /> ► 1, <br /> SUMPS CI - Distance to nearest: Well Foundation__ _____T'Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 Sen Joaquin County <br /> Horne 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 pny person in such manner as to becorna 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 permli is issued, I dhatl employ persons subject to workman's eompsnse <br /> tion laws of California." <br /> -rs The appiic ust ca for all required inspections. Complete drawing on rev roe side. <br /> Signed Title: Date: <br /> JI FOR DEPARTMENT USE ONLY <br /> LAApplication Accepted try Date Area <br /> i <br /> Pit or Grout Inspection by to Final Inspection by Date G <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin-County Public Health Services <br /> Environmental-Health Permit/Services <br /> - 445 H San Joaquin, P 0 Box 2008, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY PATE PERMIT N0. <br /> +{ I F <br /> EN 13.24IREV.IiA51 <br /> EN 1628 <br />