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t � <br /> APPLICATION FOR PERMIT ' <br /> MXIVED <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION JUN 2 8 1991 <br /> P O BOX 2009, STOCKTON, CA 95201ENVIRONMEWAL HEALTH <br /> (209) 468-3447 PERM IT/SCRVICr-S <br /> (Complete in Triplicate)" <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 coupliance,xith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Service$.! <br /> Job Address _ �d t C� �` " " te' __ City t Size/Acreage <br /> Owner's Name t V ddress -� fes'=` -- Phone <br /> r &11-44license No. rte-- Phonx'"f <br /> Contractor -Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well Gl <br /> PUMP INSTALLATION 8-� SYSTEM REPAIR G---- OTHER ❑ Monitoring Well p <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANKl 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 D Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> L"No-M-4slicl ❑ Gravel Pack! n Tracy Type of Casing Specifications <br /> A Public Ill Other > CJ Delta Depth of Grout Seal Type of Grout <br /> CJ k6gation Approx. Depth 0 Eastern Surface Seal installed by' t <br /> Repair Work Done [3' Type of Pump �.k�-'�'- <br /> - T M.P. State Work Dona <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is + <br /> available within 200 feet.] <br /> installation will serve: Residence__. Commerctaf_- Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - <br /> PKG. TREATMENT PLT. Ci Method of Disposal F` <br /> J Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER HED n Distance to -Foundation- P.ropemy..Line. <br /> SEEPAGE PITS i I Depth Site ; r 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 <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: "t comity that in the performance of the work for which this permit is issued, I.shall employ persons subject to workman's componsa- <br /> tion laws of California." <br /> i. The applic::MIZall <br /> required ip-spections. Complete drawing on reverse side. <br /> Signed X _ _ Title' ,IJ%rP�} -- - --._ Date: r •• — <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Date Area - _ <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: / - <br /> Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES Is <br /> -ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCXTON, CA 95201 <br /> FEE AMOUNT DUE � AMOUNT REMITTED C K H . RECEIVED BY DATE PERMIVNO. <br /> INFO <br /> EH 13.24 IREV.1/1151 'F� , <br /> fH;�•2a <br />