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w <br /> r APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES R E LCE I V 17 ' <br /> ENVIRONMENTAL HEALTH DIVISION UD <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 OCT 18 194n <br /> PEMIT E%PIRES 1 yEAg Vg0M DATE ISSUEJNVI RON MENTAL HEALTH <br /> (Complete in Triplicate) PERMIT/SERVICES <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork 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. <br /> Job Address Ciry Lot Size/Acreage <br /> Owner's Name Address Phone <br /> ContractorAu L::t Address r'M16 901 [ k-ta 334 License No.'f�16_2— Phon — 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP IN SYSTEM REPAIR X OTHER ❑ Monitoring Well f7 <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 /> fl Industrial " ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> %4loomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public f:3 Other © Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation —..Approx. Depth 0 Eastern Surface Seal Installed by <br /> I � <br /> Repair Work Done .IL]� Type of Pump H.P. i-" State Work Done <br /> Well Destruction 0 Wall Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION M DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 fast.) <br /> -installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms �1 <br /> Character of soil to a depth of-3-feet: Water table depth i <br /> SEPTIC TANK O Typo/Mfg _ Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ T Method-of Disposal <br /> Distance to nearest: Welt Foundation a Property Line <br /> I <br /> n LEACHING11 NE Cl No. & Length of lines Total length/size ? <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> Y <br /> SEEPAGE PITS I I ,Depth Sire Number <br /> SUMPS LI Distance to nearest: 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 '\ i <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 Ct <br /> C ' <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 compensa- <br /> tion laws of California." <br /> The applicant must fw all required in clions. Complete drawing reverse side. <br /> t: <br /> Signed Title:, -,-•_-- Date: /o— to <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Dais � Area <br /> Pit or Grout Inspection by rOate Final Inspection by Date ° <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 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE y AMOUNT REMITTED CA$H iiECEIVEO BY DATE PERMIT'NO, <br /> EN 13.24 JAEV.,/A 54 _ f� [ 1�� ���1/�✓ _ <br /> EM 74.2a <br />