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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> ' �. <br /> P O BOX 2009, STOCSTON, CA 95201 ENVIROINMENTAL HEAL <br /> ��� z � ��5� <br /> PFMIT EXPIRES I YEAR FROM DATEISSUED <br /> R ,�� ��� <br /> ( plate in Triplicate) ��-5-_ <br /> CES <br /> Sim Application is re made ttoSm Joaquin Count for a permit to construct and/or install the work herein described. This <br /> application is a in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Pblit ealth Services.. <br /> Job Address AD City Lot Size/Acreage <br /> M�� WA - <br /> ca 14 -30? <br /> Address k ` "'•C T"� — Phone v <br /> Owner's Name p1 <br /> Contractor Address A ,Y ' � � License No. 46 57fol—Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ ­WELD REPLACEMENT-❑ DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ j SYSTEM REPAIR OTHER ❑ Monitoring well <br /> C7 .t <br /> DISTANCE TO NEAREST: SEPTIC TANS('..: SEIVER-ONES'�-"'— """ w� DISPOSAL FLD. PROP, LINE <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS ! <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SSPECIfiCATIONS 4 <br /> L1 Industrial ❑ Open Bottom p Manteca Dia- of Well Excavation _ Dia. of Well Casing I <br /> } Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ j Specifications i. <br /> 1°I Public Ill Other [1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth t'I Eastern Surface Seal Instaltad by <br /> Repair Work Done L] Type of Pump k H.P. 210 *--State Work Dff <br /> one <br /> Wall Destruction ❑ Wall Diameter '—/ Sealing Material i Depth <br /> Depth !a;Jk2f !_ biller Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is <br /> ✓ available within 200 feet.) <br /> Installation wHI serve: Residence_ ' Commercial_ Other <br /> r <br /> Number of living units: Numbsi of•bedrdoms <br /> Character of soN to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ' I Capacity No. Compartments <br /> E <br /> PKG. TREATMENT PLT.❑ 1 Method of Disposal i t <br /> Distance to nearest: ' Well Foundation Property Line \ 1 <br /> LEACHING LINE Cl No. & Length of lines Total length/size ��yy <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS 11 Depth j { j Size Number ' <br /> SUMPS LI Distance to dearest: i Welt Foundation Property Lina <br /> I DISPOSAL PONDS ❑ ! t <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 I <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 /> unifies the folio ; "I certify that in the parformar6 of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of i <br /> The applica t callfor all req lr inapectio s. Com eta drawing on r ver ids. <br /> Al— <br /> ."..-glg� Title: 14Date: <br /> A-RTMEN SE ONLY <br /> —Applicitid-n ecepted by — T Data ' "Area <br /> s <br /> 6 i <br /> Pit or Grout Inspection by Date final Inspection by T � Date ^.� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDK H RECEIVED BY DATE PERMIT•NO. <br /> INfO ��,vA <br /> . EH 1121 IREV.r w 5lIm <br /> J ! 7 <br /> EM 11•Za iM <br />