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APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES : r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 b <br /> (209) 468-3447 <br /> I pEMIT ERPIR$S 1 YEAR PROH DATE Tj5SUED <br /> I[�j (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 complianceivith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> �1W City C Lot Size/Acreage <br /> S Address U, 0� � rC� -- Phone <br /> Avwner's Name <br /> Contractor 5.L!Y -� 1-_Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL L7 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL PLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Ois. of Well Excavation Dia. of Well Casing �1 <br /> U Domestic/Private 0 Gravel Pack. ❑ Tracy Type of Casing Specifications <br /> M Public 171 Other <br /> 13 Delia Depth of Grout Seal Type of Grout <br /> 0 Irrigation ox, De th Wit❑ Eastern Surface Sedl installed by - <br /> Repair Work Done U Type of Pump Q L H.P. _ State Work Done, <br /> Welt Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Y, Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NE INSTALLATION f] REPAIR/ADDITION Tri. DESTRUCTION CI (No septic system permitted if public Bawer is [ <br /> available within 200 feet.) Ir a <br /> Installation will serve: Residence.--`I Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet:'I Water table depth <br /> SEPTIC TANK Cl Typo/Mfg, Capacity No. Compartments <br /> PKG. TREATMENT PLT, Cl � i, Method of Disposal <br /> n • <br /> Distance to nearest: Well" Foundation Property Line <br /> th/size <br /> LEACHING LINE ❑ No. & Length of lines Total len 9 <br /> FILTER BED n .Distance to nearest; Well f Foundation Property Line <br /> "'i <br /> SEEPAGE PITS I I Depth F A Sirs Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i I- <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 Josquin'County <br /> Home owner or licensed agent's signature cenifies 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I the.11 employ persons subject to workman's compensa- <br /> tion laws of California." at <br /> The applicaDtmust call for all�r q Mspectiio�n1s. Complete drawing on reverse side <br /> Signed X, Y' il V�` rSC_r�__ _: Title: j Date: <br /> DEPARTMENT USE ONLY �. <br /> Application Accepted by Data '3 AreVW fa <br /> Pit or Grout Inspection by Date Final inspection by Date to ms's Qp <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 2008, STOCKTON, CA 90201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO GASH <br /> i _ <br /> . Ek t,-24(REV.,,R bl S n-� �,sa u3z� (7-3 <br />