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I , <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' 44 ENVIRONMENTAL HEALTH DIVISION <br /> 1!445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I <br /> PERIdIT <br /> EXPIRES 1, YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application In hereby made to San: Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in eomlpliance.with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations ofSan <br /> Joaquin County Public Health Services. <br /> i' Job Address r IA City Lot Size/Acreage <br /> r <br /> Owner.* Name _�!I 1� C �f}�,�Address 1 ` Phone <br /> S � �•s :.1-.j..._.:.�._ �_ _ }moi i __ ___ <br /> Contractor I A <br /> Address D License No. one S <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br />�f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATIONs —T AGRICULTURE WELL _ —QTFfEF 1iVELL Y �" ` PITS/SUMPS—_ <br /> III INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I') Public 1-1 Other 1 Cl Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation _ _Apprax.}Depth 17 Eastern_ Surface S_eui_Installtld by <br /> if Repair Work Done 0 Type of Pump H.P. - - State Work Done_ <br /> Well Destruction ❑ Well Diameter 'Sealing Material i Depth <br /> Depth !Flier Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION hl PAIRIADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is <br /> � available within 200 feet.l <br /> Installation will sena: Residence , Commercial z Other <br /> Number of living units: Number of <br /> Character of sal to a depth of 3 feet: _X/ rr Water table depth <br /> SEPTIC TANK. 0 Type/Mfg,f Capacity_,L, No. Compartments <br /> Method PKG. TREATMENT PLT.❑ i <br /> d of Disposal <br /> Distance to nearest: We4 ,Foundation Property Line <br /> �f f <br /> LEACHING LINE o. S Length of lines { Tetef length/size <br /> FILTER RED 0 Distance tonearest: -- i ---Foundati n Property Line <br /> {1 p <br /> SEEPAGE PITS I I Depth Size �7ber <br /> SUMPS L istance to pasrest F all 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, an <br /> rulas and regulations of the San Joaquin-County <br /> u <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 of subcontracting 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 Is f California." 1 <br /> The applica t at c II f I s t' s. Co t;drawing averse site. <br /> S" i� �. Title: lJ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by -"-" ��" Area <br /> Date r <br /> Pit or Grout Inspection by Date Final Inspection byl Date <br /> Additional Comment@: <br /> A I � <br /> pplicant - Return all copies to:, Skin Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT R/EMiTTEO �GA�JSH`n RECEIVED BY ATE PERMIT'NO.CH 13-24 <br /> 14-20IREV. <br /> EH 1 <br /> L [tel! v <br />