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i <br /> APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 AZ.. <br /> f} <br /> (Complete in Triplicate) <br /> Application is hereby made•to San Josquin County, for a permit to construct and/or install kr ¢ rscribed. This <br /> application is made-in compliance with San Joaquin County Ordinance No. 549 and 1862 and tl ep4(Lnd� lq`'tio>zs'bf San <br /> Joaquin County Public Health Services. t f /fit A�f <br /> Job Address ll *Cit Lot Size/A <br /> ?Rwr,s Name . . ,_ /14ddres�7►'' I_�(E' G�V�S„ _ v <br /> ne <br /> Acerise No.-�Kkv Phone � I ' <br /> TYPE OF WELL/PUMP: NEW WEL ❑ WELL REP LACEMEN M DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK` T 'SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELL----- PITS/SUMPS <br /> INTENDED E TYPE OF WELL'-. PROBLEM AREA -CONSTRUCTION SPECAN_C4TiONS�"` "" .. .r w. .�J <br /> n Industrial ❑ Open Botiom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> omeatic/Private ❑ Gravel Pack ❑ Tracy Type o[ Casing Specifications u3 <br /> ❑ Public I'1 Oilier= , pe of Grout <br /> t ` -' Clti. © Delta Depth of Grout Seal <br /> 0 Irrigation �.,Approx. Dep h Q11�stern S�rrf 'e Seal installed b <br /> Repair Work Done U Type of Pum _P_ • H.P. —`SW or D no 0Ua -7 <br /> Wall Destruction O Well Diameter -7/j?, Sealing Material i Depth <br /> �Oe <br /> --� Filler Material i p'th ��. .ti Depth <br /> TYPE OF SEPTIC WORK: NE.%6 STALLATION LD REPAIR%ADDITION CT DESTRUCTION U INo septic system permitted if public sews i <br /> i available within 200}eat,1 - m <br /> Instillation will serve: Residence-==—Commercial Other �^ i •�, <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet, T I -. , b '"• <br /> Water tabfedepth <br /> SEPTIC TANK.�__0:T. l.Mf ! + . i <br /> YPa 4-- ----�..�No-Compartments <br /> Method of Disposal <br /> r <br /> Distance to nearest: Wel! Foundation Property Line ' z <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FILTER BED CI Distance to nearest: Well Foundation Property Liner <br /> SEEPAGE PITS 11 Depth 1, Size Number <br /> SUMPS LI Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS ❑ - �, <br /> f hereby certify that l have prepared this applicationand thai the work willha done in accordance w�iFi San losqurtluntY o dinari"cis;state-laws, and `t <br /> rules and regulations of the Sin 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 sub-contracting signature <br /> carlifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject u workman's compansre <br /> tion laws of California,' a <br /> The applica s1 cal or ifedl inspections. Complete drawing on revers de: <br /> Si Title: Dater / <br /> -f <br /> R DEPARTME-NT USE ONLY <br /> Application Accepted by _ Data Area t <br /> Pit or Grout Inspection by Datet <br /> Final Inspection by � Date <br /> Additional Comments: , <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES h <br /> 445 N SAN JOAQUIN, P O BOX 2008, BTOCKTON, CA 95201 <br /> FEE <br /> INFO TED SH <br /> AMOUNT DUE AMOUNT REMIT �K RECEIVED BY DATE PERMiT'NO. <br /> CA <br /> r <br />. Eli 13.241AEV.I/AS? y p <br /> EH <br />