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APPLICATION FOR PERM[I T � �/ t <br /> SARI JOAQUIN COUNTY PUBLIC HEALTH SERVICE VED <br /> ENVIRONMENTAL HEALTH DIVISION F <br /> P O BOX 2009 STOCKTON, CA 95201 <br /> (209) 468-3447 plr , f99TAIrj' <br /> PMIT EXPIRES 1 YEAR PROM DATE ISSUSTJfTjS �� �;CqL T <br /> (Complete in Triplicate) k � YC ; <br /> A by q y permit to construct and/or install the work herein des c bed. This t r <br /> r <br /> Application is here made to San Joaquin County'-for a <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and.Regulations of Ban <br /> Joaquin County Public Health Services. ' <br /> _ � � ? _ <br /> Job Address � ���'�A—__ s.,nr�►; � City Lot Size/Acreage <br /> Y <br /> if <br /> N.t_ . <br /> Owner's Name /Ovtit+ -.*IZL r- Address <br /> Contractor�L �C� L.�•L� Address 6vai a'k-, % License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n " DESTRUCTION 0 Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ k� ',OTHEg-d;-'Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- PITSISUMPS <br /> 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑.Tracy Type of Casing tSpecifications <br /> M Public CI Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Ci Irrigation Appror, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done M, Type of Pump' H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth i Filler Material A Depth ,Zeu <br /> TYPE OF,SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION.0 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> N available within 200 feet,I <br /> Installation will serve: Residence...._- .Commercial Other <br /> t Number of living units: Number of bedrooms <br /> f Character of soil to a depth of 3 feet: Water table depth <br /> j SEPTIC TANK `p J .`p Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT."Cl w" Method of Disposal <br /> ;Distance to nearest::. _Well Foundation -• Property. Line <br /> I <br />{ LEACHING LINE ❑ No. & Length of lines f Total length/size <br /> Y � <br /> ,y '+FILTER BED C] Distance to nearest: Well� � Foundation Property Line <br /> SEEPAGE PITS I I-Depth Sire 4 Number <br /> 511MP5 " LI Distance to nearest:_ Well Foundation Property Line" ' <br /> DISPOSAL.PONDS* ,' ❑ <br /> I hereby comity that I have prepared this application and that the work will be done^iri 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 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 /> comilies the following: "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 California." <br /> 4. The applicant irn` t call for al required inspgctions, Complete drawing on reverse side. <br /> Signed Title: <br /> Si -C/• 1 <br /> g Date: <br /> 4 <br /> r O EPARTMENT USE ONLY <br /> Application Accepted by f Date Area 1 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> t -. - <br /> 1 Additional Comments: _ <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> l 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> IF E AMOUNT DUE AMOUNT HEMITTED CK RECEIVED By DATE PERM17 NO,FO <br /> { <br /> tH 14-A tREV.1/1% 3�.- <br /> EM 114-A72- Me,- J to <br />