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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> {ION IM-14f 1 r `ENVIRONMENTAL HEALTH DIVISION <br /> 445_ <br /> N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT &WIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Ss here made to San J y permit to construct and/or install the vork herein described, Th16 <br /> Alip by Joaquin Count for i <br /> application is wade in ccovliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> City -^Lot Size/Acreage <br /> Owner's Name ddress Phone g GO <br /> I <br /> 1' <br /> ContractsIR 7&0^J2Address License No. Phone <br /> TYPE OF WELL/P MP: NEW WELL O WELL REPLACEMENT . DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well O s <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 y <br /> 11 Industrial U Open Bottom O Manteca Dia. of Well Excavation Die. of Well Casing <br /> f 1 Domestic/PrivetsCi Gravel Pack %,0 Tracy ' Type of Casing_._ Specifications <br /> f'I Public I7 Otho J; fl "is i Depth of Grout Seal Type of Grout J <br /> G <br /> _ , I 1 Irritjatan �Approx. Depth I 1 Eastern Surface SwF Installed by � <br /> Repair Work Done U Type of Pump,_ H.P State Work Done _ <br /> Well Destruction 0 Well Diameter Sealing M-terial i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ]Or REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sower is <br /> Installation wig serve: Residence-C Commercial_ Other.. <br /> Character of sod to s depth of 3 feet: _ <br /> Numbs of living units: Number of bedrooms available within 200 Isat.V <br /> � , l <br /> r• w��. Water table depth <br /> SEPTIC TANK O Type/Mfg .P.L '-t' Capacity o No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ <br /> Method of Disposal <br /> Distance to nearai t: Well IP b Foundation�_ Property Line <br /> LEACHING LINE Ci No. i Length of lines Total length/size �\ <br /> FILTER HED O Distance to nearest: Well Foundation *fo Property Line _!L_ <br /> SEEPAGE PITS 11 Depth _SireNumber <br /> SUMPS LI Distance to nearest: Well Q` Foundation ! A Proarty Lin,_ D <br /> DISPOSAL PONDS O 1 ' I <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 _ _i <br /> Hone owner or licensed agent's signature oertifiies the following: "I certify that in tt;e performance of thework for which this permit is issued,I shall not <br /> employ any person in such rter►ner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the folbwing; "I caftffy 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 must call for as req^inspections. Co lets drawing on reverse side. // <br /> Signed Tide: _ ¢_ Date: �L <br /> c <br /> ti R <br /> DEPARTMENT USE ONLY LL <br /> Application Accepted by maw Date 12� F�L Area C) <br /> Pit or Grout Inspection b 0 K <br /> Y Date final7nspeotlon by 1--?' Date <br /> Additional Comm,nts: Ib <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> H 445 N San Joaquin, P O Box 2o09, Stkn, CA 95201 <br /> INFO AM04JNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED EY DATE PERMIT NO. <br /> • EN 1}bl IAN.U11'1 1 `�'t tv p QQ 1 <br /> EM U.� 1 Ir ) 1 5d <br />