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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> pEUIT E%PI_ItTS 1 YEAR ROId DATE ISSUER <br /> (Complete in Triplicate) <br /> k Application Is hereby made,to Sad Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made iri compliance; with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r // �j <br /> F /l,33 / f � City <br /> Job Address _ r _ _ r� Lot Size/Acreage <br /> F Owner's Name ti, 6_9q � � AddressZ1WPhonew T <br /> Contractor�1�� til '\ �11�� 1 Address License No. e ;)_9 Phone s( <br /> TYPE 6F-WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well <br /> -- ^-DIST-A-NCE-T-0-NEAREST;YSeP'Tlc T SEWER-LtNES RfSPOS4t'FLD f?ROP-L'tNE <br /> t FOUNDATION' � AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial © Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Weil Casing . <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing f Specifications ' <br /> M Public CI Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CI Irriomion Approa, Depth lU Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well'Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth I ° Filler Material & De h kJ <br /> f _ ` Vv <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION M (No septic system permitted if public sewer is <br /> available within 2t10 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 feetT Water table depth <br /> k SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 i 'Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE XL­�o. & Length of lines otalrlength/size <br /> t, FILTER BED n Distance to nearest: Well.--. r� F,oandation 0Property Line - <br /> r <br /> SEEPAGE PITS 1.--Depth Size f umber <br /> j. SUMPS y Ll Distance to nearest: Welt POD Foundation (� Property Line <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 regulation$ 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 /> certifies' <br /> rthe 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 law's alifornia." <br /> The applicant st all for re )red ' pact o s., _ late drawing on_r .. ae side: i f <br /> Signed Title: _ [ _ Da <br /> —«--.... -�.. <br /> t r t . .' F_OR DEPARTMENT USE ONLY <br /> + 7 t $ - r/ <br /> 3 <br /> Application Accepted by Date rea <br /> It Grout Inspection by Odd-�� 4 �Final Inspection by ate�V <br /> f Additional Comments: - <br /> r <br /> Applicant - Return all copies toi SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL-HEALTH-DIVISIONrPERNIT/SERVICES <br /> fr 445 N SAN JOAQUIN, P O PPA 2049, STOCKTON, CA 95201 <br /> f FEE AMOUNT DUE AMOUNT.REMITTED CK RECEIVED BY DATE ZPERM17'NO. <br /> k INFO <br /> i <br /> • EH 13.24INEV. Ie 51 f/ F l� <br /> EH 74.26 oo GT - <br />