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APPLICATION FOR PERMIT D`fl yLc.� Cpm <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 9 <br /> ENVIRONMENITAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 / J <br /> P O BOX 2009, STOCKTON, CA 95 1 wliS a t�•''' ` <br /> PERMIT EXPIRES YEAR FRB TE <br /> (Complete in Triplicate) stu.� <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <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., J r/ <br /> Job Address Z L�t�t� � ��`� City v/�C Lot Size/Acreage <br /> Owner's Name ��`f!1� �" � "Address <br /> Contract l"v �AddressLicense No!��.�ActL--Phone 7 `l <br /> TYPE OF WELL/PUMP: e NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Yell 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> EI Domestic/Private ❑ Gravel Pack 1) Tracy Type of Casing_ Specifications <br /> I'l Public f-1 Other 1­1 Delta Depth of Grout Seal Type of Grout <br /> I I lrr4ation _-__Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material 4 Depth <br /> Depth biller Naterial 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION^ REPAIR/ADDITION I I DESTRUCTION i I Mo septic system permitted if public sewer is <br /> L � avail leth 2Q0 feet.IL � <br /> Installation will sem ____-: Residence GCommercial_ix�_ r <br /> Other �-� �'+r�� C} <br /> Number of living unity: Number of bedrooms <br /> Character of soil to a depth of 3 feet: OC Water table depth 2- 3 <br /> goo ❑ Type/Mfg L� Capacity tem No. Compartments Z <br /> PKG, TREATMENT PLT.0 � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line;?Vc r <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, d <br /> rules end regulations of the San Joaquin County <br /> Home owner or licensed agent's signature eenifies the following: '9 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 ftallo ' "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 o ifor r <br /> rTap ant call f ;eel ct' s. Complete drawing on r arse side. <br /> L <br /> -- �✓ <br /> Signed Title: r C __ ,,... Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Pit or Grout In y f 2 9Z <br /> spectian b Date Final Inspection b ,[ � /�- DaAte <br /> Additional Comments: / / 1ma�ryy/ /�l�v <br /> Applicant - Return all copies to: San Joaquin County Public Health Services 45Y&RI -,-"d1aZ41 v- v wX <br /> Environmental Health Permit/Services / /War dor /Cjr� S,�L 04 <br /> 445 N San Joaquin, P O Hoa 2009, Stkn, CA 95201 C <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASHCEIVED 9Y ATE I PERMIT'N0. <br /> /' <br /> . EM 13.74(AM t i m a) //Y, /,/� $ 2 <br /> Y, <br /> EN 14.X <br />