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APPLICATION .FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 11%E C"I" 1 U <br /> P O BOX 2009, STOCSTON, CA 95201 <br /> (209) 468-3447 MAY 2 0 1991 <br /> PERMIT EXPIRES 1 YEAR PROM DATE ISSUEDENVIRONMENTAL HEALTH j <br /> (Complete in Triplicate) PERM JT/SERVICES <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 1562 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City ^��Dc. Lot Size/Acreage <br /> ►y !! , <br /> Owner's Name. � _�4 0 _ _ Address °�� � IZL�t] �_ Phone <br /> Contractor ( Lil fA.SL Address License No.�L_L Phone <br /> 7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Gl <br /> PUMP INSTALLATION Q SYSTEM REPAIR OTHER O Monitoring well ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F.LD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUGTION•SPECIFICATIONS <br /> M Industrial 0 Open Bottom O Manteca —Dia, of Well Excavation Dia. of Well Casing <br /> Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Cl Public is Other 0 Delta Depth of Grout Seal Type of Grout I <br /> GI Irrigation r_Approxi Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump -- d ._. H,P. _ _.moi - State Work Done <br /> Watt Destruction O Well Diameter /U Sealing Material i Depth ` <br /> Depth A S(.__ _ Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION L7 DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 feet,) <br /> Installation will serve: Residence.__.. Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK, ❑ Type/Mfg Capacity No. Compartments Q <br /> PKG, TREATMENT PLT.❑ T _ _Method of_Disposal <br /> Distance to nearest: Well, Foundation Property Line <br /> r <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Lina - I <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS Lt Distance to nearest: Well Foundation ,,_Property Lino - <br /> �. <br /> DISPOSAL PONDS ❑ � <br /> 1 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 latvs of California." Contractor's hiring or sub-contracting signature <br /> cartifies 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 Cal farms." I , <br /> The applic nt m t call for all requir din Peeti 'rls. Complete drawing on v s side. <br /> Signed �+�� Title: �� 1 'A Date: =�T " <br /> VV <br /> If DEPARTMENT USE ONLY <br /> Application Accepted by Date „_, Area <br /> �1 <br /> Pit or Grout Inspection by Date 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 /> T <br /> INFO AMOUNT DUE AMOUNT REMITTED CASN RECEIVED BY DATE PEAMIA7'NO. <br /> EH 13-24IREV. <br /> EH 14.26 'l Me <br /> i <br />