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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 0 BOX 2009, STOCKTON, CA 95201 <br /> { I <br /> PERMIT EXPIRES l YEM FRH DATE ISSUED <br /> (Complete 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 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 /> Job Address es R- City Lot Size/Acreage ,:"2 _ <br /> te/-/37 <br /> Owner's Name >� 0� �7TG %�1 Address "d f/ Phone <br /> - 0D <br /> ContractoF"'*�'s��� _ _ _ r_ iWr&ess 1it17� License No.S5���� Phone <br /> TYPE OF WE NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Te-11 0 <br /> We <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERi� /oG illy�I7 <br /> DISTANCE TO NEAREST: SEPTIC TANK —N SEWER LINES --�-- DISPOSAL FLD.,✓ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL N//t OTHER WELL6ed " PITS/SUMPS tZ <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing All* \/4 <br /> [I Domestic/Private ❑ Gravel Pack7 El Tracy Type of Casing_ Specifications �t <br /> i <br /> I'1 Public F1 Other n Oita Depth of Gout Seal Typa.of Grout <br /> I I Irrigation _Approx. Depth �a$tarn Surface Seal Installed by Ai <br /> Repair Work Done LJ Type of Pump H.P. Suite Work Done <br /> Wel! Destruction ❑ Well Diameter Sealing Material i,Depth �1y77,W <br /> Depth Filler Naterial i Depth a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION E I INo septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence_ Com"W61111_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> a- <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property L'&,tmIlIT <br /> LEACHING LINE b No. 6 Length of lines Total length/size T Q <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property LigJ <br /> x <br /> SEEPAGE PITS It Depth Size Number SAN I t GES <br /> SUMPS t` L1 .Distance to nearest: Well Foundation Prq� <br /> DISPOSAL PONDS. ❑ tIV <br /> I hereby certify that I have prepared this application and that'the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County .. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I$hall not <br /> employ any person in such manner as to become subject to workman's compensation laws of'Celifornia." Contractor's hiring or sub-contracting signature <br /> I 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 compensa- <br /> tion laws of California." <br /> 3 <br /> k The applican st 11 for all r9quired ih tion . Complete drawing on versa side. <br /> k` � d��CJ�r�ll�s 7—r Date: � L - <br /> Signed Title: . <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date -� ` Area c' <br /> Pit or Grout Inspection by �s�-8'c�[ Date b�3 Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: ea Joaquin County Public Health Services S,v <br /> Environmental Health Permit/Services �*1 <br /> 445 N San Joaquin, P O Box 2009 Stkn CA 95201 <br /> F CK C� <br /> EE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITN0. <br /> i INFO GASH <br /> r EN 13.24 IREY.I/R sl <br /> EH use UU v <br />