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APPLICATION FOR PERMIT <br /> � - i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 1 O V 0 3 1992 <br /> S liq A)A,QIJIN COUNTY <br /> FZMIT EXPIRES 1 YEAR FROM DATE ,ISSUED F1'-:_IC HEALTH SERVICES <br /> (Complete in Triplicate) LNC I(�OfdAAENTALHE/V[4DIVISION <br /> Application Is hereby made to Sant Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade in compliance 1 with San Joaquin County Ordinance No. 549 and 1862-and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r <br /> Job Address _� � 44-,7d, _ City Lot Size/Acreage <br /> t <br /> 14'y,�� <br /> // <br /> Owner's Name `"'s�"� `j Address Phone <br /> Contrac ` � AddreSE 7 License <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ZP�- OTHER D Monitoring Well <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 Ind trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing <br /> omestic/Private O Gravel Pack O Tracy Type of Casing Specifications <br /> M Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> G Irrigation �- Approx.'Depth r� Eastern Surface Seal Installed by + <br /> Repair Work Done L9' Type of Pump , _ H.P. 1� State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth OVL ia:EA-rr4v <br /> Depth t�Idler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D 'REPAIR/ADDITION-M DESTRUCTION G INo septic system permitted if public sewer ism "! <br /> �l 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT ALT. ❑ Method of Disposal $ <br /> Distance to nearest: Well Foundation Property Line . <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire -- <br /> FILTER BED 1-1 Distance to nearest: Well Foundation Property Lina � <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation 'Property Line <br /> DISPOSAL PONDS ❑ <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 ceraity"that in the performance of the Zo-rk for which this permit is issued, I shall not <br /> employ any person in such manner as to become subjiect to workman's compensation laws of California. Contractor's hiring of 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 workman's compensa- <br /> tion laws of California." <br /> The applicant mus Or all required ins Illictions. Complete drawing on rev Ile side•K <br /> s _ ra - <br /> Signed X.�. ,. ._,...._._ Title:4 Data: ' <br /> FOR DEPARTMENT USE ONLY ' <br /> f ! <br /> Application Accepted by Date U Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments; <br /> Applicant - Return all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> FEE INFO AMOUNT DUE AMOUNT REMlTT.ED� RECEIVED BY GATE PERM17'NO. , <br /> + EH 13-22.1lIEV,rixsrrrw <br /> 1cH"4.26 <br /> r <br /> Y <br />