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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES l YEAR FRQM DATE I S Nfl C� <br /> (Complete in Triplicate) �-L .��. <br /> Application is hereby made to Sea Joaquin 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Z9 City d t Size/Acreage <br /> 1.Owner's Name / Address - �`- �d�', ' Q / �c _ Phone <br /> J. <br /> Contractor G Address License No. Phone <br /> -'r TYPE OF WELL/PUMP: NEW WELL ❑"(-" WELL`REPLACEMENT"17 " " " DESTRUCTION ❑ Out of Service Kell ❑ <br /> PUMP INSTALLATION ❑ i ce.. m SYSTEM REPAIR,0_ OTHER ❑ Monitoring Well <br /> ❑ {/pl��\``\4 <br /> t y V <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES pISPOSAL'FLD. PROP. LINE <br /> t FOUNDATION 4 AGRICULTURE ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE T TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca_ Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> (1 Public fl Other 1 n Delta Depth of Grout Seal # Type of Grout <br /> I I Irrigation _Approx. Depth I 1 Eastern Surface Soul Installed by l! } <br /> Repair Work Done Ll Type of.Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth r <br /> Depth Filler Material i Depth ' <br /> .TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I RUCTION I s�pria`system permitted it public sewer is <br /> I """�"^I • aitsble within 200 feet.) <br /> Installs will serve: Residence-___ Commercial- Other r <br /> !Number of living r' �Numbsof bedrooms <br /> Character of sod to depth t: R., atei table depth <br /> SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ y , 4, 1 Method of Disposal <br /> r Distance to nearest Well <br /> undation Property Line <br /> LEACHING LINE ❑ No. b Length'of linea a """' I length/-Size— <br /> FILTER BED 0 Distance to t. Well Foundation y Line <br /> SEEPAGE PITS 11 th Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line l <br /> DISPOSAL S ❑ <br /> certify that I have preparid this application and that the work will be done in.accordance with San Joaquin County ordinances, state laws, and I <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature rcenifies.the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such mariner 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 workmen's compensa- <br /> tion laws of California." '� W <br /> The applicant must call for all required inspections. Complete drawing on rev side. <br /> n { I <br /> Signed X., Title: Data: )W � <br /> a,. OR DEPARTMENT USE ONLY <br /> Application Accepted by o, Date 3-3- 53 Area_ 52- I5 <br /> Pit or Grout inspection b li <br /> Y Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all :,copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Boar 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DAY PERM 77 +NO. <br /> . EH 13.26 InEv,t i n 6i * Qd <br /> EH 1 .26 <br />