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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 /> I <br /> f <br /> 1PERMIT EXPIRES 1 YEAR FROM DATE S <br /> (Complete in Triplicate) <br /> Application is hereby made to Sit] Joaquin County for a permit to construct and/or install the vork berein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. / <br /> Q v� <br /> t Job Address / City Lot Size/Acreage �j r <br /> M CTCDAddress �Ip�� LO vel rphone fv� -3(t/ 0 <br /> Owner's N4 me I/'�'J <br /> Contractor' yC: ice'""Address_ - License No 30672/ Phone <br /> 4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Ll <br /> OTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR"❑-� .__ <br /> DISTANCE TO NEAREST:•'SEPTIC TANK SEWER LINES DISPOSAL FLD,"�""'"RPROP. LINE <br /> r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM ARW'CONSTRUCTION SPECIFitATIONS <br /> i Cl industrial ❑ Open Bottom ❑ Manteca Dia.of Well-Excavation_ Dia. of Well Casing <br /> CI Domestic/Private ❑ Gravel Pack ❑ Tracy ; Type of Casing' Specifications <br /> I"I Public 'ta,Other fl Delta Depth of Grout Seal f Type of Grout <br /> I I Irrigation ti—.AppP!10 -Depth---l-l"Eastern--.,,y,_SuYrface Seal Installod by ° <br /> Repair Work Done L] Type of Pump H.P. "'" ' ,StMe Work Done <br /> FWWell Destruction ❑ Well Diameter = -�-�� Sealing-Materisa-4 Depth <br /> %, Depth_ '' # gip_ Piller Material A Depth <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted it public sewer 4 <br /> available within 200 feet.) <br /> N Installation will some, Residence Commercial ��Other <br /> Number of li►ring units: Number of ooms <br /> Character of sod to a depth of 3 feet:' __ Water table depth l <br /> � - <br /> SEPTIC TANK tom_."-_d�_ Type/Mfg- �� CapacityZ&6Q No. Compartments <br /> PKG. TREATMENT PLT. ❑ (i r 11 e Method of Disposal <br /> 4 ! Distance to nearest: Well� Foundedy n `�1 <br /> �SSProperty Lina !� r <br /> LEACHING LINE ❑ No. k Length of lines r-2 1 Co 0 " Total length/size Q r, <br /> FILTER 8ED ❑ Distance io nearest. Well / / Foundation - Property Line 1� <br /> r t/ - <br /> SEEPAGE PITS , 14--Depth 5 SizeNumber <br /> SUMPS Ll Distance to nearest: Wall CA/D� Foundation �t 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 regulations-of.the San Joaquin County <br /> Horne 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 following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- <br /> tion laws of California." '1 <br /> The applic $Icalfor all uir inspections. Complete drawing on reverse side. <br /> ,I <br /> I Signed Title: N --- Date: <br /> t r FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area o� <br /> t <br /> Pit or Grout Inspection by �'- // Data Final Inspection by Date -2 <br /> Additional Comments: Zy N � -- -- — <br /> Applicant - Return all copies to: San Joaquin County public Health Services <br /> Environmental Health Permit/Services <br /> f f 4451N-Sari Joaquin', P O Hox-�2009, Stkn, CA 95201 <br /> e. <br /> r FEE AMOUNT DUE AMOUNT REMITTED _COSH RECEIVED pY DATE PERMIT-ND. <br /> INJ /`F�O <br /> EM 3.24 EM1�yIREv.1/115 !V f J 00 �f�� 6$ <br />