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a <br /> APPLICATION FOR PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ; <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 12�{ Q.�u1; rir4 !: DlLComplete 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 /> application is made 1n cospliance.vith Ban Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin Count Public Health Services. <br /> Job Address JL itY <br /> Lot Size/Acreage .i <br /> 1--6wner's Name Address <br /> Phone <br /> t ' ! <br /> Contractor Address License No. . s7irJf Phone • <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Kell <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring well ❑ ;.. <br /> -+ DISTANCE TO NEAREST: SEPTIC TANK... SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A CULTURE-WELL OTHER YyELt "PITS7SUMPS <br /> "INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t � <br /> El Industrial ❑ Open Bottom ;❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> )Domestic/Private ❑ Gravel Pac k7 n Tracy Type of Casing Specifications <br /> !'1 Public fl Other P Delta Depth of Grout Seal Type of Grout <br /> I <br /> t I Irrigation —.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. 6/O &,A2 State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth v <br /> Depth Tiller Material 4 Depth <br /> _ r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is i <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of-bedrooms <br /> Character of soil to a depth of 3 feat: Water <br /> tSIENT <br /> a <br /> SEPTIC TANK ❑ T �. <br /> yqa/Mfg Capacity No. C <br /> PKG. TREATMENT PLT. ❑ Matho� <br /> Distance to nearest: Well Foundation Property Lin .Q 993 <br /> LEACHING LINE Cl No. 6 Length ofAnea Tatei length/ <br />!k FILTER BED ❑ Distance to nearest:. ._.Wall Foundation --- --:Pr&W0kAAFfdT'A1,kI�A1 TH DIVISION- <br /> SEEPAGE PITS I I Depth Sire Number < <br />,,—SUMPS =-„r. Ll_ .Distance_to_naaresl:. Well” -- -._Foundation-' Property—Line-1 <br /> DISPOSAL PONDS ❑ <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 /> I 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 /> certifies the folio "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of <br /> The applican call for all r uir inspsctio s. C etc drawing on raver ids, <br /> Signed 0 Title: Date: " <br /> FOR DEPARTMEN SE ONLY G� <br /> Application Accepted by Date r� Area k <br /> Pit or Grout Inspection by Date' Find Inspection by Date (_- <br /> Additional Comments: � � ,4t-0 <br /> Applicant -• Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services _ <br /> 445 N San Joaquin O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED K I RECEIVED BY PATE PERMIT NO/. <br /> OD <br /> . EH 1341 fREV.riw57 5� 11 ��/ `7 9 <br /> EH 11.2a l <br />