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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIGES <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> P O BOB 2009', STOCKTON, GA 95201 <br /> (2019) 468-3447 <br /> PERMIT ESPIRES 1 _XFAR_ PROM PATE ISSUM <br /> (Complete in Triplicate) <br /> Application is hereby made,to Sari Joaquin County for a`permit to construct and/or install the work herein described. This <br /> application is wade 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 /> Job Address �' C �' City r Lot Size/Acreage Ll <br /> Qt6 kQ(-TL. Po m b Address h �� '�" fil .0/-/ L <br /> Owner's Name —� <br /> Contractor ���}�`e. r Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ 4WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ OTHER 0 Monitoring Well El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICU,LT_URE WELL " OTHER WELL PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca j Dia, of Well Excavation Dia. of Well Casing "V <br /> U Domestic/Private 0 Gravel Pack n Tracy Type of Casing Specifications <br /> M Public El Other © Delta Depth of Grout Seal Type of Grout t� <br /> CJ Irntjation ._.Approa. Depth 0 Eastern " Surface Seal Installed by <br /> r <br /> Repair Work Done D Type-of Pump. H.P. 'M State Work Done <br /> Watt Destruction 0 Well Diameter Sealing Material i Depth <br /> f <br /> Depth lillfer Material A Depth ` <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION REPAIR/ADDITION M DESTRUCTION G INo septic system permitted it public sewer is <br /> �J available within 200 fast.l <br /> Installation will serve: Residence Commercial_ •Qth�r <br /> Number of living units: Number of bedrooms 4 r <br /> Character of $oil to a depth of 3 feet: I k. Water table depth <br /> SEPTIC TANK 0 Type/Mfg ,�a 1�G�"e l'Q 'I� - - - Capacity ��6 No. Compartments <br /> PKG. TREATMENT PLT.Cl �� �IM�--- Method of Disposal <br /> Distance to nearest: Well Foundation z3 Property Linec.L <br /> LEACHING LINE No. & Length of lines J 160.1 Total lengthlsize <br /> FILTER BED CI Distance to nearest: Well l Foundation Property Line L-�06 <br /> SEEPAGE PITS 11 Depth l ' Size Number <br /> SUMPS Ll Distance to nearest: Well I`M Foundation -., Property Line <br /> DISPOSAL PONDS ❑ i! EM. <br /> I hereby certify that I have prepared this application and that the work will be'done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin[County 1. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not <br /> employ any person in such manner as to'become subject to workm[an'sleompenaation-laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work1for which this permit I$issued, I shall employ persons subject to workmen's compenss- <br /> tion laws of California." <br /> i The applicant must Call forpalloguired inspections, Complete drawing",.reverse.side. r} <br /> r Signed Title: owN�r Date: <br /> OR DEPARTMENT USE ONLY ' <br /> I <br /> Application Ace opted by ff' Date Area c� <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> i f <br /> Additional Comments: _ <br /> Applicant - Return all copies to: , SAN _JOAQUIN COUNTYILPUBLIC-HEALTH SERVICES_ <br /> k -ENVIRONMENTAL HEALTH- DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN tP 0 BOX 2009, STOCXTON, CA 85201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED] CASH RECEIVED BY DATE PERMIT'NO, <br /> . q <br /> ♦ em U•21InarV.�In510���'zo. RO- gob3 <br />