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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEM <br /> ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 ��. <br /> (209) 468-3447 JAN Q <br /> ENVIRONMENTAL HuALTH <br /> (Complete in Triplicate) PERM IT/SERVI%�:3- <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 grade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.. <br /> Job Address Cit Lot Size/Acreage <br /> ..e <br /> 0 rter'a Name /��� �� ddress _ Phone f <br /> I. Or2-I&A�� Nc. t1 �I Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11DESTRUCTION 0 Out of Service well C} <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring well [7 �✓ <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f ` <br /> IN7ENDED E70-YPt- i INE[L �'PROBL'EM AREA�­C0 STRUCTION`SPECIFICATIONS' <br /> ' f <br /> 0 Ind strisl ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Castng,- <br /> fr ,L „, ,,-rZype..of_Casing Specifications <br /> I M Public f'1 Other ❑ Delta t 1Depth'of Grout Seal ' Type of Grout J <br /> CA urruation pprox• Dop1hEastern Surface Seal Installed by <br /> 'LIO' Repair Work Done U Type of Pu •H.P. State Work one _ <br /> 7 Well Destruction 11Well Diameter ___ F__._ °Yi"g Material Depth <br /> Depth `1 Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION G INo septic syslam permitted it public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence Commercial Other <br /> Other <br /> Number of living units: Number of bedroomsw <br /> Character of soil to a depth of 3 feet: Water table depth <br /> f h SEPTIC TANK. ❑ TM/Mfg F Capacity No, Compartments <br /> Q PKG. TREATMENT PLT. 0 t Method of Disposal <br /> Distancerto nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines _ Total length/size <br /> FILTER BED 171Distance to nearest: Well. Foundation Property Line <br /> SEEPAGE PITS I I Depth Sue _ Number - <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> _4r <br /> DISPOSAL PONDS ❑ 1 -0, ` <br /> t;;.,_ I-hersby.csrtify-thatd-have-prepared-this-a pplication-and-Ihahthe-work-wilt-be done_in:.accofdanct�wiih;San'JbaQuin'county-ordinances; state laws"amd-" — <br /> rules and regulations of the San Joaquin County r <br /> Home owner or licensed agent's signature certifies the following:/'I.certify_that-in•the pertor:mance--&-the-work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to.workmad's ccomperi`satio-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 workman's compensa• <br /> tion laws of California." <br /> The a/ppliet call f �dkns• Completedrawing on rs rse side. /� (�-Sind c 1 �` Titl Date: /APIA/ <br /> OR DEPARTMENT USE ONW G <br /> Application Accepted by Date 7� Area <br /> Pit or Grout Inspection by Date Final Insppction,b ��` Date 2 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES - <br /> 445 N SAN JOAQUIN, P 0 8071 2009, STOCKTON, CA 95201 <br /> IEEE A✓/MODUNT DUE` fA�JMOUNNNT�REMITTEO CASH RECEIVED BY DATE PERMIT'NO. <br /> . E„l`. IREV.rixpr <br />