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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR <br /> (Complete in Triplicate) <br /> Application is hereby made to San 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. +"�`-7� �f <br /> Job Addrass City :Lkw of Size/Acreage <br /> C .. <br /> Owner's Name Address Phone 35 <br /> Cantrac dres�* �'►' r5o cense N _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O 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 /> f-1 Industrial © Open Bottom © Manteca Dia, of Well Excavation Dia. of Weil Casing <br /> omesticJPrivata ❑ Gravel Pack 0 Tracy Type of Casing f � � Specifications <br /> M Public f-1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> 0 irrigation Approx,.DepthQ] Esstern�-1-I- Surface Seal Installed by <br /> Repair Work Done [1), Type of Pump, H.P, 1 State Work Done _ <br /> Well Destruction ❑ Weil Diameter - Sealing Materialy4 Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION Ci DESTRUCTION G Mo septic system permitted if public sewer is <br /> available within 200 feeLl <br /> Installation will serve: Residence — Commercial r„_.. Other <br /> Number of living units: — Number of bedrooms <br /> C . <br /> �ti Character of soil to a depth of 3 feet: Water table depth <br /> ),L -SEPTIC TANK -ii- ❑ Type/Mfg I Capacity -- --- No. Compartments <br /> PKG. TREATMENT PLT. Cl of Disposal <br /> Distance to nearest: Well Foundation Pr * v <br /> LEACHING LINE ❑ No. A Length of lines Total 14 Atr�/s' R <br /> FILTER BED ❑ Distance to nearest: Well Foundation r%, 9 rodrlY/nin <br /> SEEPAGE PITS I l Depth t Sire Num�er� <br /> SUMPS LI Distanca_lo nearest:--- -m--- •---Foundation --~- Property <br /> I <br /> DISPOSAL PONDS ❑ W err <br /> I hereby certify that I have prepared this application and that the work wil€ be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County i <br /> Home owner or licensed agent's signature cenifies 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 following: "I canify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's <br /> compensa-tion Iowa of California." <br /> i <br /> f The applicant must ca required inspe ns. Complete drawing on rse side. <br /> Signed X i -____ Title: _ Date: <br /> t OR DEPARTMENT USE ONLY <br /> 4'Z1.6 <br /> ' Application Accepted by Date Area _ <br /> 5 Pit or Grout Inspection by Date ntin y cUt <br /> k0AettAoo>ctG �2 <br /> 1 - wee c.cvv. <br /> Additional Comments: s w to erred <br /> ' all c r@.s Q.� r` c-1-. . a ae f rut '�ic5 arm # S$-,7p-! d oQry <br /> I Applicant - Return L10-pies to: S JOAQ N COUNTY PUBLIC HEALTH SERVICES r ! <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 20D9, STOCKTON. CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO,__ <br /> . EN 1 .24 IREV.1 In 5) P� ov `fes OZ) b 2,3 1 6-0 Z 4 QZ 1(?Z-,Zfa <br /> EH <br />