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�. . _ APPLICATIQN. FOR PERMIT <br /> 3 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 /> PERMIT EXPIRES I YEAR FROM DTE I§SURD <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 Sawn Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. JI <br /> 11"J �J��P /f ��iNl� f City Lot Size/Acreage / <br /> ' Job Address Io <br /> �'a0 !Y !✓rv1�7 S !�- <br /> Address Phode <br /> Owner's Name Z5>'� ll! <br /> . J� � 3 3 V—gq56.• <br /> Contractor 6�`�� d``^ � Address License No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT •n DESTRUCTION ❑ put of Service wall C1 t <br /> �. Monitoring.. fell <br /> P INSTALLATION O SYSTEM REPAIR'OOTHER I]- „� `� <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLD. PROP. LINE__ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL--PIT /SUMPS ' <br /> INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTIO (CATIONS Q <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. xcavation Dia. of Well Casing <br /> n pomastie/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> Specificatbna <br /> i"1 Public l- Other n Depth of Grout Seal _ Type of Grout <br /> - <br /> Il <br /> De 1 I Eastern ON <br /> Seal Installed by y L! <br /> I I Irrigation , <br /> Repair Work Done L7 Type of P p H.P. State Work Done <br /> Well Destruction ❑ WeU.Diameter ` Sealing Material i Depth <br /> Depth hiller Material i Depth , <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> �vailabie_within 200 feetA <br /> I Installation will serve: Residence Commerci Other <br /> Number of living units: Number of bedr s <br /> Character of soil to a diptwof 3 fast: Water table depth <br /> SEPTIC TANK. 1 Type/Mfg••, 6 �` Capacity -� --Na.-Compartments <br /> PKG. TREATMENT PLT, ❑ ' . _� Method of Di I ' `� ' -rte C �' <br /> = _Distance to nearest: Well ISP Foundation J — Property Line f ~r <br /> t � t <br /> t LEACHING LINE, No. b Length of lines �' �otal length/size t�J <br /> FILTER BED C7 Distance to nearest: - Well Foundation Property Line <br /> 1 <br /> k <br /> + SEEPAGE PITS i I Depth �SizeNumber 2 <br /> r <br /> SUMPS '\WA Distance to nearest: Well Foundation Property Line <br /> F DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with SaW.Ioaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County . <br /> Home owner or licensed agent's signature certifies the•foliowing: "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 subcontracting signature <br /> certifies the following: "1 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 /> The applicant must call for all required inspections. Complete drawing on reverse side. In <br /> Signed )( � Title: <br /> FOR DEPARTMENT USE ONLY 2 <br /> r <br /> Application-Accepted by <br /> Dots � Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> r. Applicant - Return all copies to.:—San;Joaquin County Public Health'Services <br /> Environmental Hes Permit/Services <br /> ti 445 N San Joaqu Box 2009, Stkn; CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DAT PERMIT'NO. <br /> INF 11 <br /> . EM 13-24111Ev.tins <br /> EM 14.20 <br />