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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 'J <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 ^ <br /> P 0 BOX 2009, STOCKTON, CA 95201 / ! <br /> j PERMIT EBPIRES 1 YEAR FROM DATE ISSUED <br /> f (Complete in Triplicate) <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 mode in campliaace with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health SSerrices. <br /> Job Address I t���l. f) Lot Size/Acreage <br /> nnOFF <br /> eerr''sssNNam�eYn}L L./}'( rye �1 (1,, I1 �� Address 1 Phone <br /> ^(R�)� <br /> 'CohlQ _ /IJVA.CX,ANdre 4 n�e No. <br /> Ir TYPELL/PUMP: NEW WELL ❑ WELL REPLACEMENT .. DESTRUCTION ❑ Out of Service 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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial _ _-_ O Open Bpttom -❑ Manteca, __ - Dia. of Well Excavation Dia. of Well Casing <br /> Nroomastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - - - Specifications <br /> I'1 Public n Other _ n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _yp .Approx. De h I Eastern 1 wAace Seal Installed by <br /> Repair Work Done U Te of Pum H.P. to State Work Dona ' <br /> WON Destruction ❑ Well Diarm Sealing Material i Depth v� � <br /> Depth - Tiller Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic'system permitted it public sewer is <br /> available within 200 Iestj <br /> Installation <br /> will serve: Residence_ Commercial_ Other O <br /> Number of living units: _ Number of bedrooms <br /> Character of sole to a depth of 3 feet: Water table depth <br /> SEPTIC TANK- - ❑ Type/Mfg Capacity No. Compartments v l <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE ❑ No:8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to newasu Well Foundation Property Line � <br /> DISPOSAL PONDS ❑ - 1 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end <br /> roles and regulations of the Sen Joaquin County - <br /> ---Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fur 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 /> certifies the following: '7 certify that in the perfomanco of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion taws of Calif is 11 - <br /> The applie in <br /> cell or caked inspectionzs�.�Complete drawing onre r side. �-� <br /> Sprted L-yr dam' Title: kz�a Dasa:, <br /> FO EPARTMENT USE ONLY <br /> 1. .f <br /> Application Accepted by - Date L Area U ^/ <br /> PK or Grout inspection by Date Final Inspection by ! ; Date rT <br /> i <br /> Additional Comments: <br /> i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS CEIVED BY DATE PERMWO10- /[ <br /> INTO �_r, 9�_oJ �7 <br />