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' b�L H•�,Lvys�f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -J' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 f <br /> liECEIVEV <br /> (209) 468-3447 SE P � f <br /> PWIT ERIM 1YEAR-92M-DATE, ISSUED "NViRONMENTAL HEALN <br /> (Complete in Triplicate) "ERMIT/Sg <br /> f7V1C��� <br /> Application is hereby trade to Sao Joaquin County for 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public }Eealth Service <br /> Job Address A301_SS•. �A!kyi l-y�Q�j„ City Lot Size/Acreage <br /> t <br /> Owner's Name Address Phone <br /> Contractor', - Address,:b 4`,?-S-30icense No,q-r3 yC Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0i DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 9--' SYSTEM REPAIR OTHER ❑ Monitoring Well E� <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 /> (7Instrial ❑ Open Bottom ❑ Manteca Dis, of Well Excavation Dia. of Well Casing <br /> Dome <br /> Domestic/ L Grave! Pack 11 Tracy Type of Casing Specifications <br /> t <br /> ❑ Public 11 Other 0 Delta Depth of Grout Seal Type of Grout <br /> CJ lrripatiori /�'`Approx. Depth 0 Eastern Surface Seat Installed by <br /> Repair Work Done 10 Type of Pump H.P. State Work Done <br /> Weft Destruction 0 Well Diameter Sealing Material & Depth r <br /> Depth Filler Material 6-Depth— <br /> TYPE <br /> iDepth TYPE OF SEPTIC WORK; NEWINSTALLATION 0"-REPAIR/ADDITION Cl DESTRUCTION G (No septic system permitted if public sewer is <br /> ,4 -" ' , ,. — available within 200 feet.) <br /> Installation will"serve: Residence— Commercial_-,- Other a <br /> Number of living units: Number of bedrooms <br /> Character of$oil to a depth of 3 feel. Water table depth y. <br /> SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments - <br /> PKG. TREATMENT PLT. 0 t Method of Disposal ` <br /> Distance to nearest: Well Foundation -f Property Lina <br /> f k 7 <br /> G C <br /> LEAHINLINE C1 No. & Length of lines r <br /> � 9 <br /> FILTER BED n Distance to nearest. Well Foundation Property Liner~ <br /> I <br /> SEEPAGE PITS 11 Depth Size :Number f <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 reputations 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 subcontracting signature <br /> Certifies the following: "I certify that in the perlormance 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 11 required inspec ions. Complete drawing on verse side. r <br /> Signed Title' - Date: r <br /> P <br /> R DEPARTMENT USE ONLY <br /> Application Accepted byDate �+ Area <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 O BOX 2009, STOCKTON, CA 95201FEE it <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, j <br /> �►n( �' I/ � <br /> . EH 19.2 (REV.rind Pl„ 7 <br />