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.n_ APPLICATION FOR PERMIT ' 1 <br /> s <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 7 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 'i P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM-_DATE_1S83JED <br /> ;M (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This I <br /> application is made 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 fl City Lot Size/Acreage .�/'/L• - J <br /> Owner's Nam Sep /` Ador <br /> dress �/G�7 'f � Phone <br /> -est <br /> Contractor Address �0 27 I License Nrf! /Y3 2­5Phone <br /> TYPE OF WELL/PUMP: i NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER 0 Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> * Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> 11 Public � 17 Other n Delta Depth of Grout Seat Type of Grout <br /> I I Irrigation i —Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done U I� Type of Pump H.P. State Work Done _ <br /> Well Destruction 0 Well Diameter Sealing Material A Depth <br /> Depth biller Material i Depth <br /> I <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is <br /> II available within 200 feel.) <br /> Installation will serve; Residence____. Commercial Z_ Other <br /> Number of living units: Number of bar oo s r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg - �e _ Capacity�L No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I'I Distance to nearest: Well Foundation- Property Line <br /> LEACHING LINE CI No. & Length of lines Q Total length/sire Q <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth Sire l Number ' <br /> SUMPS Ll Distance to nearest: Well O� Foundation - Property Line <br /> DISPOSAL PONDS O <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 <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 signetur <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 l <br /> tion laws of California." ' <br /> The applets t mutt fpr I required ' s�ns. Comp to drawing on reverie side, <br /> Signed Title: _ Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by I;I Date ? Area a�/ <br /> Pit or Grout 1 II <br /> napection by Data Final Inspection by ,+�� Das 4 > � <br /> Additional Comments: Y l c-/ OX 'If t ull's. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services - ��a`SX-5 <br /> EnvII 4451 NoSanntal Joaquin,Health Permit/Services <br /> Stkn, CA 952017'ok� l'"°"te(,d A 5r be- <br /> UW <br /> FEE <br /> ,w^'`� <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVEp BY DATE PE+7RM.IT. Np. <br /> EH$31.21 tPt v.'1/1161 ! �r d v '�. ,7"if��� i� �� a_-,•'. <br /> EH N•9a M <br /> '�IrSlu2 fl�.�tr r_t ;c� 1'3 F_ iCrlfA a -f., !._L 1,'- l'e r 11.E Ain,.,.'\ <br />