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NAPPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 MAR <br /> (209) 468--3447 <br /> ENV,,RONMF11 TH <br /> PERMIT URIIERS 1 YEAR PROM DATE I SSUIR ERM 17 <br /> (Complete in Triplicate) <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> p r <br /> Job Address 9�3� dP ___1141__ City.. Lot Size/Acreage <br /> Owner's Name - �� � Address Phone <br /> Contracto 1 � - Address License No. 3��� Phone <br /> TYPE OF WELL/PUMP: NEW WELL CI WELL REPLACEMENT 0 DESTRUCTION L-) Outof Service Weil ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR D OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLA. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS +I <br /> CA Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing l <br /> Domestic/Private Cl Gravel Pack D Tracy Type of Casing Specifications 1� <br /> C7 Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CI IrriUation -_Approx, Depth 0 Eastern y Surface Seal Installed by <br /> Repair Work Done 11� Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 4 Depth rA <br /> Depth Filler Material & Depth ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CJ (No septic system permitted if public sewer is <br /> available within 200 feet.) Al <br /> Installation will serve: Residence Commercial,,,,-,_, Other _7 Y <br /> Number of living unite Number of bedrooms <br /> Character of soil to a depth of 3 fest: <br /> P Water table depth <br /> SEPTIC TANK, ❑ Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Trine <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n, Distance to nearest: Well- --Foundation-- - - Property.Lime 1 <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONOS ❑ s <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 cenify 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 sub-contracting signature <br /> certifies 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 /> i <br /> The applicant must c or all require¢inspgctions. Complete drawing on reverse side, x <br /> Signed Title:I'—_ _ .~7 <br /> Data: <br /> 0:=. -74�NT USE ONLYApplication Aeoapted by Date <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> 4Z//(1/9/ <br /> Additional Comments: _ I <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, ST=TON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RK I ECEIVED By DATE PERMIT NO. <br /> . EH13-24MIV.1iw51 � 3�(D , RI - a4 <br /> EH'4.2a <br />