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I� <br /> :t <br /> APPLICATION FOR PERMIT <br /> !� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRC41ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I� <br /> 'F PERi[IT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I; <br /> . (Complete in Triplicate) <br /> :t <br /> Application is hereby made,to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �, —/7 ]�`� <br /> Job Address Z- �� y�--I-s/ {.� City Lot Size/Acreage <br /> Owner's Name s` es4c Address Z5 � Phone <br /> Contractor ''` II 3 g Address 0? !�/����® License No, Phone <br /> TYPE Of WELL/PUMP: NEW WELLA WELL REPLACEMENT CI DESTRUCTION 0 Out of Service well ❑ <br /> I PUMP INSTALLATION SYSTEM REPAIR 0 F _ OTHER ❑ Monitor" Well ❑ <br /> DISTANCE TO NEAREST,: SEPTIC TANK SEWER,LINES" '� DISPOSAL PA <br /> � - FLO. OP. LINE s��y <br /> II FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS 174. f+ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Oome$tiCiPrivate >eGravel Pack 0 Tracy 't 1 Type of Casing, = Specificationsle�y"/vo <br /> Il Public I! (.1 Other (� Delta Depth of Grout Seal ��� Type of Grout <br /> I i Irrigation -01,1 In.. .; <br /> A� Approx, Depth 1 i Eastern ''Surface 5ea1 Installed by <br /> Repair Work Done L3 iE Type of Pump SQA s H,P. — . - State Work Done <br /> Well Destruction ❑ I�Wel! Diameter i Serilii4 Material A Depth <br /> Depth _ tiller Material-i"Depth. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION.I.1 DESTRUCTION I I (No septic stem permitted i! ~ <br /> Il ,. may. P Y pe Public hewer is <br /> ti--.& _.,,,,;., 4, available within 200 feet.) <br /> Installation will serve: Residence_____ Commercial_ Other r <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: ' Water table depth_� <br /> SEPTIC TANK. p Type/Mfg ' Capacity} ' ` � Nb. Cornpartments <br /> PKG..TREATMENT PLT.0 MethBd of Di <br /> ��1' <br /> �. Distance to nearest: Well <br /> Foundation 1�17Property Lime r <br /> LEACHING LINE El No. fir Length of linea _ Z Total length/size <br /> FILTER BED ID Distance to nearest: Well "'Foun­dafion" —.Property Line <br /> SEEPAGE PITS I I Depth t Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation f ; Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this applica4ion and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County j <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 1J <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor'$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 ompan" <br /> tion laws of California." i` �. I <br /> The applican ailt tions. Complete drawing on reviyse.,side. <br /> Signed Title: Date: <br /> r OR ENT USE Y <br /> O q i 1 <br /> Application Accepted by �� Date _� `� _ Area 4 1 <br /> i <br /> PitGrtw napection by P Date Final Inspection by Date <br /> 4i;)" _ <br /> . Addilbniil CdrtirisnEe:"v �✓$� �7: lrvC'��' w J <br /> Applicant - Return all copies to: San Joaquin County Public Health S 'vices <br /> 'Environmental Health Permit/Services <br /> } 445 H San Joaquin, 'P O'Boxv2009, Stkn, CA 85201 <br /> FEEf s /I�NgF/OJ AMOUNT DUE AMOUNT REMITTED K RECEIVED BY O TE PERMIT•NO <br />„ - rH-11-2 -1 REV.r i e si <br /> EM 1476 <br /> q <br />