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3 * 3o <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ` P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> EERXIT ES 1 YEAR ]?ROM DATE I SSUED <br /> I (Complete in Triplicate) <br /> 4 <br /> Application is hereby made to Seri Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in c=Wliance 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 157,6 2,6 (J City , Lot Size/Acreage <br /> f <br /> Owner's Name ,rffisa Address {" Phone1?419 <br /> Contractor Address10-4 C6 License No. A_r2& _2a Phone �9�z•aea <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION Cl Out of Service Well C1. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public til Other �.. O Delta Depth of Grout Seal Type of Grout <br /> Ci Irrigation �..Approx.lDepth- ❑ Eastern Surface Seul Installed by <br /> Repair Work Done U Type of Pump •H:N." ,State Work.Done <br /> I Welt Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler I�tltriel & Depth <br /> * <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION.CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms Z' <br /> Character of soil to a depth of,3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg - ----Capacity--�- No.-Compartments <br /> i PKG. TREATMENT PLT, C] Method-ofDisposal <br /> Distance to nearest: Well Foundation Property Line . <br /> LEACHING LINE No. & Length of lines Total length/size <br /> s <br /> FILTER BED ! n Distance to nearest: Well r fiu Foundation_ I _ Property Line <br /> SEEPAGE"PITSI I Depth" Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby comity that I`heve prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home 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 any person in such manner as to become subject to workman's compensation laws of California." Contractor'i hiring br sub-contracting signature <br /> eerlifies the following: "I certify that in the performance of the work for which this permit is issued, I shell employ persons subject to workman's componsa- <br /> tion laws of California." 4 <br /> The applicant must call for all required insWtlons. Complete drawing on reverse side, <br /> Signed X Title: !CgZ Date: <br /> -ZWLDEPARTMENT USE ONLY <br /> 1 <br /> Application Accepted by Date Ir A Area �___ <br /> Pit or Grout Inspection by Date Final Inspection by Date r d <br /> Additional Comments: ! l <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> J ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMpUtJT REMITTED . -., CASH-- - RECEIVED BY- --DATE PERMITNO,: <br /> EH1]-24 IREV.t i n si <br /> EH - ` <br /> ,,.m <br /> y <br />