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1 APPLICATION FOR PERMIT <br /> SAN JOAQDIN COUNTY PUBLIC HEALTH SERVICES , <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1 <br /> P O BOX 2009, SToCKTON, CA <br /> (209)" 46$-344? <br /> R <br /> t' (Complete in Triplicate) bed. This <br /> I <br /> ! for a permit to construct and/or install the work herein described. <br /> Application is hereby made,tloiaSam ce vithuSanCJoe4Y <br /> application ie made in comtR <br /> Nin county ordinance No. 549 and 1862 easel the Rules and Regulations of an <br /> JoKuin County Public Health/Services. Lot give/Acreage <br /> L�� �T city <br /> Job Address Phone f r <br /> Address �f <br /> Owner's Name y Phon <br /> Cyd/,tr License No. .�s ---� - V <br /> Address DESTRUCTION ❑ Out of Service Well ❑ <br /> Coniractor�- WELL REPLACEMENT [7 Monitoring Well C3 <br /> NEW WELL D `"` - OTHER ❑ <br /> TYPE OF WELL/PUMP. T SYSTEM REPAIR L PROP. LINE <br /> PUMP INSTALLATION ❑ DISPOSAL FLD.�-� r <br /> A SEWER LINES =— �-•" .PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC"TANK ­ _-.�--- AGRICULTURE WELL OTHER WELL <br /> --- �7 <br /> FOUNDATION ---� ° <br /> INTENDED USE TYPE OF WELL PROBLEM� REA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia, of Well Excavation _ _•SpeCificationa- <br /> fD industrial ❑ Tracy 7Ype of Casing Type of Grout <br /> U Domestic/Private C! Gravel ❑ Delta " Depth of Grout Seal <br /> M Public #1 Othor / <br /> 5uriaee Seal Installed by <br /> CJ Irrigation Appraic• Depth D Eastern t State Work Done <br /> ' H.P. <br /> Repair Work Done U Type of Pump ----- Sealing Material 1st Depth <br /> I <br /> Well Destruction O Well Diameter --�— }Tiller Material i Depth <br /> Depth <br /> available within 200 leet:l ' <br /> TYPE Of SEPTIC WORK; NEW INSTALLATION !� AEPAIRIADDITION" DESTRUCTION Gi ifJo septic system permitted if public sewer i , <br /> v <br /> Installation will serve: Residen� Commercial Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to,a depth of 3 fees: Capacity��------ No. Compartments <br /> 4 SEPTIC TANK, 'h*" 0" Type/Mfg Method of Disposal <br /> PKC. TREATMENT PLT.❑ <br /> Distance to nearest: Well <br /> Foundation Property Lina <br /> I y Total length/size <br /> LEACHING LINE j No. & L'ength of lines Properly Line <br /> + ,50 t'" Foundation �---- <br /> FILTER BED fa'. Distance to nearest: IWell _ f . <br /> �f1.4 <br /> Number <br /> Depth I ` � _Sire •• Q <br /> SEEPAGE PITS Rc3f Foundation ' Property Line <br /> ' SUMPS LII Distance to nearest: Well- �—�- <br /> 0? <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 g performance of the work for which this permit is issued, I shall not <br /> Home owner Or licensed agent's signature certifies the following:16win 1 comfy that in the or sub-contract <br /> employ any person in such"manner"-as to become iubfact to workman's compensation laws of California:" ploy persons subject to workman's compensa- <br /> certifies the following: "I cenify that in the performance of the worketor which this permit is issued. I shall employ pe , <br /> tion laws of California." I <br /> The applicant must call for IN required inspections. Complete drawing on reverse side. Z r9 f <br /> Date: <br /> Title: <br /> Signed ^* <br /> R DEPARTMENT USE ONLY..., <br /> Date a Area <br /> _ ^ <br /> Application Accepted by �b <br /> f Final inspection bye" � pats <br /> Pit or Grout Inspection by Date - —. <br /> Additional Comments: <br /> Applicant - Return all copies 1 4UIN CoUkY,to: SSAN JONzdENTAL HEALTHOA1UDIVISION,PERUIIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> CK RECEIVED BY DATE PERMIT"N0. <br /> FEE MOUNT DUE AMOUNT REMITTED CASH C `� <br /> . INF <br /> . EH 13•24IREV.1 1$5i <br /> EH it,•'� } <br />