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APPLICAT)ON-FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 'P O BOX 2009, STOCKTON, CA 9.5201 a <br /> (209) 468-3447 <br /> tl y <br /> YEAR PROM DATJL_�� <br /> I (Complete in Triplicate) <br /> Application is hereby (made to Sam Joaquin County for a permit to construct and/or install the vont herein described. This <br /> application is made in coupliance 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 +!'. City Lot Size/Acreage <br /> d� <br /> /�/� /�6/ ICdd_ _• �/ST///� - - Phone �� <br /> Owner's Name � F <br /> Contractor <br /> �S Address.21� 1�� License No. �/fOOUPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL FIEPLkCEMENT,11r DESTRUCTION 0 Out of Service Nal f <br /> Monitoring <br /> INSTALLATION wel <br /> PUMP INSTALLSYSTEM REPAIR 0 OTHER ❑ t C7 <br /> +� -�' DISPOSAL FLD. �� PROP. L <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> INE �€ <br /> : <br /> FOUNDATION7- AGRICULTURE WELL == OTHER WELL�� - PITSISUMPS e�o I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� r <br /> 1.1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ /Z-- Dia. of Well Casiil <br /> Domestic I Private XGfovel Pack n Tracy Type of Casing /.1!/G- _ Specilications <br /> IO public 1 1 Ot {�/ ❑ Delta Depth of Grout Seal Type of Grout Z <br /> CJ Irrigation .. • Deptthh r�❑ Eastern urface Seal Installed by <br /> Repair Work Done Ll Type of Pump _ diC� H.P. Z State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION❑ REPAIRIADDITION 0 DESTRUCTION CI INo septic system permitted if public sewer is <br /> v available within 200 feet.) <br /> Installation will terve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms i <br /> -Character of soil to a depth of 3 feet: }! Water table depth /T <br /> SEPTIC TANK 0 Type/Mfg f Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal � <br /> �.� <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> 1 � , <br /> SEEPAGE PITS I I Depth i Size Number f� <br /> SUMPS L1 Distance to nearest: Well "^" Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby comity that I have prepared this application and that the work wilt 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 foilowirig:"I'certify that in the performance of the work for which this permit is issued, I shall not r /1 <br /> employ any person in such manner as to become subject to workman's compensation laws of CalHornia." Contractor's hiring a sub-contracting signature u l <br /> eenifies the following: -J certify that in the performance of the work for which Ihis permit is issued;I shnilimploy persons subject to workman's componse• J <br /> tion laws of California." 1 r J <br /> The applicante requir c ' Complete drawing on re"arse side' <br /> Signed X Title: �~� _ Date: <br /> OR DEPARTMENT USE ONLY T * <br /> El <br /> Application Accepted by Date- Area � ' <br /> 1 O 'L �O Final Ins patk� s J© <br /> Pit or Grout Inspection by �_ 4V. <br /> ata�� Inspection by <br /> Additional Comments: C' )a f �' Z CN �� L <br /> _. . <br /> Applicant - Return all copies to:� AN JOAQUIN COUNTYPUBLICHEALTH SERVICES <br /> IENVIRONNENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 1445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 ' <br /> IFEE NFO AMOUNT DUE t' AMOUNT REMITTED GA5H, RECEIVED SY, DATE PERMIT'NO, <br /> r� -Tb A qOe-,2117-1 <br /> Zr r) GV 71 1- p <br /> . EH 13,24)REV.I?K 41 r � �-Y SO e-`Z z '1 <br /> EH,�•1e <br /> i <br />