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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 /> EMIT EXPIRES 1 YEAR FROM DATE 188UED <br /> (Complete in Triplicate) <br /> i <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 in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules aad Regulations of San <br /> Joaquin County Public Health Servi es. <br /> City . Lot Size/Acreage <br /> Job Address i <br /> Owner's Name <br /> J�llti} Address a W Phone <br /> / s 2 I& icense N Phone <br /> i Contractor `Z/!.-L. Address ` <br /> I WELL REPLACEMENT Cl DESTRUCTION C7 Out of Service well G7 I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Monitoring Well (_3 <br /> SYSTEM REPAIR ❑ OTHER O <br /> PUMP INSTALLATION ❑ ! <br /> ? DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- DISPOSAL FLD. PROP. LINE <br /> y <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA,, CONSTRUCTION SPECIFICATIONS \ ; <br /> Fes_ Dia. of Well Casing <br /> Cl Industrial, © Open Bottom O Manteca i Dla. of Well Excavation <br /> 7 0l Casin Specifications ' <br /> [.I Domestic/Private ❑ Gravel Pack t D Tracy Type g- Type of Grout <br /> Il Public I-1 Other n Delta Depth of Grout Seal <br /> 1 <br /> I 1 irrigation _Approx. Depth l I Eastern Surface Seal Installed by r <br /> Repair Work Done U Type of Pump H.P. Stats Work Done <br /> Sealing Material i Depth <br /> Well Destruction ❑ Well Diarrleter �° t <br /> t r ; Tiller Material & Depth <br /> I i TYPE OF SEPTIC WORK: NEW!NSTALLATIONY,, REPAIRIADDITION I I DESTRUCTION i I iNos Attic sy t m Permitted <br /> It public sewer is <br /> availainstallation will serve: Residence` Corrimsrcial f`�'z,Other ' <br /> Number of living units: Number of badrooms <br /> Character of soil to a depth of H feet: � Water table depth <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg ? <br /> PKG._TREATMENT_PLT.-O-- ? `' Method of Disposal <br /> w, � <br /> 4, <br /> Distance to nearest: Well _ Foundation /. �r Property Line <br /> LEACHING LINE 1 No. b L'en`gth of lines, <br /> A Total length/size <br /> t'.�'? '°Foundation Property Line <br /> i FILTER BED ❑ Distance to nearest ,Well�:- <br /> i <br /> Number <br /> ` <br /> SEEPAGE PITS I 1 Depth <br /> /��. Pro Lina <br /> I SUMPS Distance to nearest: Well oundatio'ri Pe►ty - <br /> ' DISLIOSAL PONDS �. ❑>t'. : <br /> I hereby certify that I have prepared this application and that the work-'w&be done in accordance with San J6aquin`county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Homo owner or licensed agent's signature certifies the-following: "i certify that in the performance of the work for whicKthis permit is issued, I shall not <br /> ampby any parson in such manner as to become subject,tp.workman a-'coifrpensatian laws of California." Gontratitor's hiring or sub cantracting signature <br /> F " certifies the following: "I certify that in the performance_otthe work for which'this permirisisaued,!shall employ persoris`wbject to workman's compensa <br /> 1 tion laws of California." j <br /> The applicant must call or air iii coons. Complete drawing on roversa side. - + A <br /> i Title: Date: <br /> Signed <br /> FORD R E.ONLY <br /> # Application Accepted by Date s� rea <br /> p <br /> Pit or Grout Inspection by Data Final Inspection by ,Oat <br /> Additional Comments: <br /> r Applicant - Return all copies to: San Joaquin Count Public Health Services µr_„_. _ �. ._>- -•- <br /> I - �- linvl'roRmeittia Health Permit%$'ervices - <br /> 445 N`Sae'Jos tIfn, P'O-Box <br /> "2009;�Stk1i;'CA 95201 <br /> E FEE AM tJN7 DtIE '� L,. AMOUNT REMITTED SASµ RECEIVED BY SATE PERMIT'NO. <br /> IN <br /> IN 13.24IIIEV,I/N5I <br /> EH 1476 <br />