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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PIMIT LUIRES 1 YEAR VRQM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby amide 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 J <br /> Health Services. /y <br /> Job Address Q d 42 •yOK� V� City Lot Size/Acreage {fie <br /> Owner,a Names e d U► i Address A/ 4Ale-& � — Phone <br /> Contractor& dc <br /> X �!S Address 2�s k /`��K" License NoA 62]1). hone-- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> w <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF NLI. PROBLEM AREA CONSTRUCTION SPECIFICATIONS sem` <br /> n industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation pia, of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ' ❑ Tracy Type of Casing Specifications <br /> M Public 11 0 her ❑ Delta Depth otrGrout Seal Type of Grout <br /> ❑ Irrigation �.Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump dH,L . k j State Work Dons <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth "Ffller'Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION BEPAIRIADDITION Irl—DESTRUCTION 0 (No septic system permitted if public sewer is <br /> _ s # available within 200 feet.) Q <br /> Installation will serve: Residence Commercial Other___, <br /> Number of living unite Number of bedrooms __ , <br /> Character of soil to a depth of 3 feat: &. Water table depth <br /> SEPTIC TANK 9 Type/Mfg 42 QnrW.41M Capacity �l BO No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> + Distance so nearest: Well.z Foundation property Line <br /> t ` <br /> LEACHING LINEf" '�-�No. & Length of lines .U-C S Total length/size—/70 <br /> FILTER BED !FT Distance to nearest: Watt 5� FoundationProperty Line _ �Q <br /> SEEPAGE PITS .+'f" Depth Size Number Z^ <br /> SUMPS -4fr Distance to nearest: Well a 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 regulations of the San Joaquin County ' <br /> Home owner or licensed agent's signature cenifies the following: '%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 cenify that in the perfbrrnancs of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion laws of California." <br /> The applican t all for all req d inspgctio Complete drawing on reverse aid / <br /> Signed J Title: 1�9 Date: <br /> �AENT USE ONLY <br /> __c(-k � D <br /> Application Accepted by Date Area <br /> Pit or Growl Inspection by f hate Final Inspection by �� Date d <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERTMIT/SERVICES <br /> 445 N SAH JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> FEE X 11 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE }� /ylPERMI-r NO. <br /> . EH 13211REV.rinyi V `, _. iB^� <br /> EN;{•7e i LJ lJ <br />