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�L w APPLICATION FOR PERMIT <br /> ~ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> � . ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468 .3447 <br /> r <br /> . OUR 1 VRA- <br /> RA- <br /> (Complete in Triplicate) �fq <br /> Application is hereby sleds to $".Joaquin County for a permit to construct and/or instaa °Gh�e`J ork t!?iein d cribed�t. This <br /> application is made in ccnpliance',vith Ban Joaquin County Ordinance No. 549 and 1862 and t �RuleeCand Rega}atiions at San , <br /> Joaquin County Public Health Services. _ f <br /> �`�� G.3• y1 City Lot Size/Acre ' erg AN _ <br /> Job Address _ <br /> � /� <br /> Owner's Name .� :�. - __ Address 3L <br /> Fr <br /> Address�U c� License No.. -Phone <br /> TYPE OF WELL/PUMP. NEW WELL Gl WELL REPLACEMENT't 1 DESTRUCTION ❑ 0'tt Monftoring Well <br /> PUMP INSTALLATION SYSTEM RE AtR:❑_ _, OTHER ❑ <br /> DISPOSAL-FLD. : — PROP.,LINE <br /> DISTANCE TO NEAREST:-SEPTIC TANK- -- SEWER=LINES PITS/SUMPS <br /> Y FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> f1 industrial ❑ Open Bottom ❑ Manteca - Die, of Well UcaevDia, of Weil Casing <br /> vation <br /> �r _ Type of-.Casings .-Specifications <br /> f6-DomesticJPrivate 0 Gravel Pack 0 Tracy Type of Grout <br /> Public Cl Other ❑ Delta Depth of Grout Seal"i rj <br />` CJ Irrioation Approx Depth C) Eastern f Surface Seal Installed by <br /> Eir��_ -_ H.P. State Work Done <br /> II Repair Work Done {] Type of Pu '0 sealing Material i Depth <br /> Wait Destruction ❑ Well Diameter j <br /> Depth f Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIWADDITION_LI DESTRUCTION 0 INo septic system permitted it public sewer is <br /> 1-1 available within 200 feet.) <br /> Installation will serve: Residence-- Commercial_____ Other ; <br /> Number of living unite Number of bedrooms k [� <br /> Character of soil to a depth of 3 feet:' t Water table depth <br /> SEPTI DANK ❑ Type/Mfg Capacity No. Compartments , <br /> PKG..-TREATMENT PLT. Cl i Method of Disposal Z., <br /> Distance to nearest: Welt Foundation Property Line <br /> I i <br /> LEACHING-LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance t to Well Foundation Property Line _ <br /> SEEPAGE PITS I l Depth f Sire Number -- <br /> I SUMPS _ LI. Distance:io nearest . Well "Foundation' �' -;—Property Line <br /> DISPOSAL PONDS r D " t <br /> hat the work will be done in accordant® with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and't <br /> rules and regulations of the San Joaquin County <br /> r 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 /> t employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> comities 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 /> Theapplicant ^f r all require�ispe.ciions. Cpmplete drawing`on reverse side. <br /> Signed X i % - Title:f Date: .� <br /> _FOR DEPARTMENT'U5>E ONLY <br /> ..� Date / b Area <br /> i <br /> Application Accepted by r <br /> Pit or Grout Inspection by Date Final Inspection by Date 23 <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 95201 <br /> CKEFEE AMOUNT DUEAMOUNT REMITTED CA51i RECEtVEO 8Y OATE PERM17'NO. <br /> + <br /> INFO /y 11-A /7 9 9 fr <br /> . EH 13.21INEV.o/A51 -- /T ',�10—?/ <br /> iV / I l.f�V <br /> i _ <br />