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APPLICATION FOR PEPWrT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � -{- g5 <br /> + NSRO�Q HEALTH DIVISION <br /> 445 ANJOIN PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201. LQ t <br /> PER1d T EZPIRE 1 YE FR m DATE. S <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> &WlicAl is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Al A,; <br /> Services. <br /> Job Address 7'7 �r /C L L t ,A fC Sic- <br /> City Lot Size/Acreage Jl <br /> Owner's Name If H 11, Address V a At <br /> Phone <br /> Contractor Address 'rf�l�///S ��� rlf <br /> TYPE OF WELL/PUMP; License NdOI�V—Phone'✓A94( 7 <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES O <br /> R �� DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> EI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> El Domestic/Private ❑ Gravel Pack �+ +4 Dia. of Well Casing <br /> I'] Public _ ❑`Tracy- , Type of Casing- _ <br /> [1 Other i ,. � Specifications <br /> n pelt Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth . I ! Eastern <br /> f Repair Work pone L] T Surface Seal Installed by V <br /> Type of Pump H.P s, <br /> Well Destruction Stats Work Dona Q, <br /> p Well Diameter Sealing Material i Depth / <br /> Depth Piller Material ,& Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION (IF1 REPAIRrADDITION I I DE57RUCTION I 1INO septic system <br /> permitted if public sewer is <br /> Installation will serve: Residence l�I available within 200 Iest.1 � <br /> Y Commercial..` Other <br />! Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. p Type/Mfg -- <br /> Water table depth <br /> Pl TREATMENT PLT.❑ Cap a y No. Compartments j <br /> �f # Method of D,i�poaal <br /> Distance to nearest: Well Li_ Foundation i'J <br /> -7— Property Line�� <br /> LEACHING LINE ❑ No. b Length of lines )6 0 <br /> FILTER BED' ❑ DiI Total length/size 111 0 <br /> stance to nearest: wall D 4 <br /> 1 Foundation 'Property Line ` <br /> SEEPAGE PITS I Depth <br /> SUMPS Size Number <br /> LI Distance to nearest: I Well ! <br /> DISPOSAL PONDS ❑ Foundation-LZ)� Property Lina <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 <br /> Hama owner or licensed <br /> such <br /> agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i she not <br /> employ any person in such manner as to become wbjact to workman's compensation taws of California." Contractor's hiring or subcontracting signature ; <br /> cartdras lits following:"I certify that in the performance of.the work far_which.this. <br /> tion laws of California." - permit-is.issuecIA-shall employ persons subject to workman's com"m"a- <br /> It <br /> The applicant s1 ll for all req inspections C plots drawing on reverse side. k <br /> Signed f , <br /> Title: Date: ` <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �q,, a <br /> Date Area_ n� <br /> Pit or Grout Inspection by <br /> Date-- � Final In by / L <br /> Additional Comments:J 13 Date 2 <br /> l r � <br /> � <br /> Applicant - Return all cop e 8 to; San Joaquin County Public Health Services <br /> Env <br /> tal Health <br /> 4451 No Sana Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> fFEE AMOUNT DUE AMOUNT REMITTED CK ' + , <br /> CASH RECEIVE)BY DATE 1 <br /> PERMf7'NO.EH 13.74 IIIEV.t i n 61 1 �� ` � f <br />