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` APPLICATION FOR PERI[I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC.E6 4"u fig <br /> ENVIRONMENTAL HEALTH DIVISION " <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 JAN 2 5 91 <br /> PERMIT EXPIRES 1 XEAR I�ROId DAT �`I `IRONMENTAL HEAL <br /> (Complete <br /> (Complete in Triplicate) PERMIT/URVIGES W <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules amd Regulatione of San <br /> Joaquin County Public HealthBegrices. <br /> r it r <br /> Job Address 65� WV Lo� �Size/creage <br /> � <br /> is �7 <br /> Owner's Nam Address Phone <br /> r <br /> j <br /> C It r rdress 0--cense No, Phone <br /> '_TYPE OF WELL/PUMP: NEWL`0 WELL REPLACEM NT n DESTRUCTION L1Out of service Well ❑ f j <br /> PUMP INSTALLATIOf SYSTEM REPAIR ❑ OTHER ❑ Monitoring well L� IP <br /> 'DISTANCE TO NEAREST: SEPTIC TANKI 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 /> n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private .❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i <br /> M Public 1.1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> G Inigution ..Approx. Depth 'Eastern Surface Seal Installed by 4r <br /> t <br /> Repair Work Done U Type of Pump H.P( State Work D _ <br /> Well Destruction O Well Diameter ' Sealing Materiai Depth <br /> i Depth <br /> Depth _ Filler Materia-- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIRlADDfTION 0 DESTRUCTION CI (No septic system permitted if public sewer is i <br /> available within 200 test.) <br /> - installation will serve: Residence_ Commercials— Other <br /> Number of living units, Number of bedrooms f <br /> Character of *oil to a depth of 3 feet: 1 Water table depth i. <br /> SEPTIC TANK ❑ Type/Mfg .I Capacity No. Compartments <br /> i PKG. TREATMENT PLT, C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line j <br /> LEACHING LINE = Cl Not&`Length of lines. Total length/size <br /> FILTER BED s� F1 Distance to nearest: r Well Foundation Property Line <br /> SEEPAGE PITS /" 11 Dapth',, Size Number 4 <br /> SUMPS b E Distance to nearest: Well Foundation Property Line ' <br /> DISPOSAL PONDS ._O� '' <br /> f' <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, an j <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agents signature certifies the fbllowing: "I certify that in the parlormance of the work for which this permit is issued, I shall not I///��� j <br /> employ any person in such manner as to.become subjec} to wo6man's compensation laws of California." Contractor's kiting or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall em_plypersons subject to workman's compenss h <br /> don laws of California."J _ - - I <br /> The appiican sl!t��c lot ))'required inspections. Complete drawing on r rae side. <br /> Sign denSRL� Title: Date: <br /> ��` i R DEPARTMENT USF ONL <br /> Application Accepted by Oats Area II <br /> I 77 <br /> Pit or Growl Inspection by IOate Final Inspection pato 2 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY-PUBBL C HEALTH SERVICES <br /> ENVIRONMENTAL, HEALT# DIVISION PEPMIT/SERVICES "' <br /> 495 N SAN JOAQUIN, P•O BOX 2008, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT <br /> TTyD7UE AMOUNT REMITTED C K I <br /> ntfRECEIVED BY DATE PERMIT'NO. <br /> • EH 13.24 TREY,iil �v �Pv <br /> ��i ✓ t a` O ��q "O1 <br /> EH 14•I6 v <br /> 1 <br />