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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> P O BO%. 2009, STOCKTON, CA 95201 <br /> (209) 468-3 73��o <br /> -. PERMIT UPIRES 1 YEAR rROM DATE I,SSUM * ; <br /> (Complete in Triplicate) <br /> Application 14, hereby made to San Joaquin County for a permit to con atruct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the.Rules and Regulations of San <br /> Joaquin County Public Health Services. G <br /> " x <br /> Job Address / � � �' v City �� Lot Size/Acreage �� / <br /> Size/Acreage - <br /> wr's Na�me ID <br /> ` 7V-; <br /> KO !C� S0- 39 V-6lEp - dress Phone <br /> jKContrac Mr Ad <br /> / <br /> TYPE OF WELL/PUMP: NEW WELL ClW L REPLACEMENT-F DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION El YSTEIO REPAIR` OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE , 'DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE ELL' 1`OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROSLEM ARE A " CONS R ON SPECIFICATIONS <br /> f 1 Industrial ❑ Open Bottom ❑ Manteca Dia. c I Excavation Dia. of Well Casing <br /> l' •L l ._ Specifications <br /> U Domestic/f rivets C7 Gravel Pack-� C3 Tracy Type o in.g <br /> C'7 Public, Cl Other (� Delta _ Dept of.Gr us <br /> Seal <br /> -- Type of Grout <br /> GI IvriUation Approx. Depth ❑ Eastern, ' S ace Sst t stalled-by" `--� <br /> h ;Repair Work Done U Type of Pump H.P. ~ - State Work Dona _ F <br /> " WeN Destruction D Well Diameter Seali Material`& D h 4 <br /> d Depth Fil r'Material�& Depth <br /> _ <br /> TYPE Of SEPTIC WORK: .NEW INSTALLATION REPAI " ADDITION 1r1...DESTRUCTION CI (No septic system permitted if public sower Is <br /> r ` available within"200 leet.1 <br /> :11n tion.will serve: Residence Comms#rcia! Other w <br /> `�'rubor o1 living units: _J_ Number of bedrooms z, k <br /> Character of soil to a depth of 3 feet: aLp Water table depth <br /> SEPTIC TANK. / Type/Mfg Capacity I�Od�ar_`� No. Compartments <br /> PKG.-TREATMENT PLT. 0 [ ` / '_ Method�oo,f��D,,i.s,p��osal <br /> Distance to nearest: Well 1400 Foundation ' - •' Property Line <br /> LEACHING UNE No. & Length of-lines_ _ --3 '~ SD ___ Total length/size O <br /> FILTER 9ED n Distanc0o nearest: WeIL 7 O Foundation _50- Property Line <br /> SEEPAGE PITS pQ Depth,..` T Sias � �� = 3 b- Number _ _3 <br /> c/O i <br /> SUMPS LI Distance to nearest: Well 06 -Found_ation Property Line <br /> DISPOSAL PONDS ❑ r?`t"' <br /> I hereby certify that I have prepared this application and that the work,willl be done in accordance-w�t 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 cartif�y that in the performance of the work for which this permit is issued, I shall not I <br /> employ any person in such manner as to become subject to workman's compensation Iowa 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 perrmil is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." r <br /> The applicant st call for all rsquir i cSians. Complete rawing on reverse side-i. <br /> Signed X Date: <br /> R i <br /> FO EPARTMENT USE ONLY <br /> Ap lication Accepted by } Data Area/ <br /> r <br /> `�Z� Final Inspection by AW, <br /> or Grout Inspection by ate- <br /> Additional Comments:. — <br /> Applicant - Returfa all copies to: SAH 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 OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO J / ( CASH '} Q C�] p� <br /> . EH13-241REV.�iM6i j114,t�t�. � OCD � J _` I ! f ~V5R <br /> EN 14.26 I 1 f <br /> I <br />