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f- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 AR <br /> pEMIT $SPIRES ] YEAR VRQ9 DATE _155UED <br /> (Complete in Triplicate) ENVIRONMENTAL HEAJH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the WoF�htdJlBlih�iiSER"ESThie <br /> application is made in compliance with San Joaquin County Ordinance Ifo. .549 and 1$62 and the Rules and Regulations of San <br />`. Joaquin County Public Health Services. <br /> Job Address , _ City Lot Size/Acreage <br /> �� Phone <br /> Owner' 'Rom Address <br /> a Name "" <br /> Contracto, Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Monitoring Well ❑ <br /> PUMP INSTALLATION f �- SYSTEM REPAIR M---' OTHER D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES= DISPOSAL FLD. PROP, LIVE <br /> FOUNO"ATIQN>-�4 AGRICULTURE WELL — OTHEA.WELL_ _PITSI-SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing Specifications QN) <br /> Public I'll Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrioation / Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done W Type of Pump H.P. .��*4, -- State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material ii Depth <br /> I TYPE Of SEPTIC WORK: NEW INSTALLATION J_1 REPAIR/AQDITION 0 DESTRUCTION 0 INa septic system permitted if public sewer is <br /> w available within 200 feet.) <br /> r i <br /> Installation will serve: Residence___. Commercial— Other GD <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK OL Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/suer <br /> FILTER BED n Distance to nearest. Well Foundation Property Line " <br /> SEEPAGE PITS 11 Depth Size try r Number <br /> k SUMPS LI Distance to-nearest: 4 Well Foundation Property Line <br /> DISPOSAL PONDS ❑ -+—.; <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 signature <br /> certifies the fotlowing: "I certity,that-in-the parfarmance.of.the-work-fof-which-this permit.is issued,_I_shall-employ-persons subject-to workman's compensa- <br /> tion laws of California." <br /> ""The applicant mus r all requ' inspections. Complete drawing on reverse side. <br /> 4 J . <br /> Signed Titre: r f Dater 3-12r_— 2 <br /> EPJR DEPARTMENT USE ONLY ` <br /> Application Accepted by 99YOM Date / AYee <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> 7-7- <br /> Additional Comments: <br /> Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED Cx RECEIVED BY DATE PERMII'NO. �v • <br /> INFO mss, CASH �1 c� 4! /�/ Q p <br /> 6H 13.24 I Itev.I/As) - t.V 1/ J'�`I'_( ( �1�L�1P L1 mss/ <br /> EH?{.2a <br />