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APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> P O BOX 2009, STOCKTON, CA 95201 N O V 0 3 1992 <br /> (209) 468--3447 <br /> SAN JOAQUIN CO0R,7Y <br /> PERMIT EXPIRM I_ypAXE ISSUW PUBLIC HEALTH SERVICES <br /> (Complete in Triplicate) t1*1 RON MENTAL HEALTH DIVISION <br /> Application is hereby made to San 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �J� <br /> { Job Address "' ` � �-A ''"�� -l-`� CltyI 1,ot Size/Acreage <br /> e>� <br /> Owner's Name '� - Address /M'*�°'�� - __ Phone <br /> -• Contract r ddre icense Phon <br /> 3 <br /> TYPE OF WELI_IPUMP: NEW WELL © WELL REPLACEMENT C] DESTRUCTION Cl Out of Service well ❑ <br /> PUMP INSTALLATION C3 SYSTEM REPAIR OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OT_ <br /> HEK WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ClIn sal ❑ Open Bottom EIManteca Dia. of Well Excavation pia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications <br /> M P,Iblic CI Other ❑ Delta Depth of Grout Seal Type of Grout 4 <br /> G Irrigation .Approx, Depth C[] Eastern Surface Seal Installed by al <br /> Repair Work Done ($� TyAs of Pump H.P. State Work Done r . <br /> Well Destruction D Well Diameter sealing Material Depth ' <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION U INo 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 <br /> Character of soil to a depth of 3 feet: r"^ Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg k Capacity No. Compartments Z <br /> .. m <br /> ' PKG. TREATMENT PLT. El "� r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L-I No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth r Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O 3 <br /> 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 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's hiring or sub-contracting signature <br /> conifiss 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 /> tlon lows of California." <br /> The applicant must call 'red inspection �mplete drawing on roV---( <br /> side: <br /> Signed ilio: - Date: <br /> 1 FOR DEPARTMENT USE ONLY Zr<� <br /> Application Accepted by .Data A Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: - <br /> 4 <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I i ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 H SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMI"EO Cx RECEIVER BY DATE PERMIT NO. <br /> INFO <br /> ♦ EH 13-$�tIEV. n SI 1.3240 <br /> _ <br />