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ys n <br /> APPLICATION FOR PERMIT <br /> ESr <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ��,yA(� <br /> �. <br /> P O BO% 2009, STOCKTON, . CA 9.5201 <br /> (209) 468-3447 <br /> !EMIT ESPIRES 1 YEAR ISR ld DATE I55MED , <br /> (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 made-in compliancelvith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address c. �, <br /> t City , ot Size/Acreage <br /> t I 4 r <br /> Owner's Name Address Phone <br /> Contractor_ '54 X_ L Address License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL © WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION,C] SYSTEM REPAIR ❑ OTHER p Monitoring Well [1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. UNE <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I M Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic I Private O Gravel Pack �❑ Tracy Type of Casing Specifications Q <br /> M Public I 1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> C! Irrigation __ Approx.eDepth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump "ti.P""`°" TT"' Stife Work Done, <br /> Well Destruction O Well Diameter > Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTA TION 0 REPAIRIADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is d\\ <br /> available within 200 fest.} <br /> Installation will serve: Residents ' 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/Mfg4Pt No. Compartments <br /> PKG. TREATMENT PLT. Q } 1 Method of Disposal it <br /> Distance to nes{f T1It F,Rlyp�a�tl Wim._ Property Line <br /> being Co <br /> LEACHING LINE ❑ No. $ Length Q},Iirtes A e enUN/f�l'UIfTgpQlr+„Fmfal iengthlsixa <br /> !JUfiV� Lt <br /> w.: <br /> FILTER BED {'l Distance to nearest-' al N�f� altip , Property Line <br /> fMn <br /> SEEPAGE PITS I I Depth "T Size Number <br /> !, SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> t <br /> DISPOSAL PONDS ❑ a <br /> t 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 Sen 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 /> 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." T <br /> The applicant must call for all u" inspections. Complete drawing on reverse tide. <br /> Signed 10�7 , Title: .V1i2d/ca4 _ ._ Date: 42 7.?.-2 - <br /> OR DEPARTMENT USE ONLY C <br /> Application Accepted bye_ ■ -o s - _ Date `� � `-� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> f Additional Comments: — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV¢ j 99TRONMENTAL H HEALTH DIVISION <br /> SAN JOAQUIN, P OBOXPERMIT/SERVICES <br /> 2009, <br /> 5TOCKTON. CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMIT'TEO CK RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> r . EH 13.24IREV.1/115i �,� :.3 Z'� �C7 0 <br /> Elf <br /> E <br />