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f,6 <br /> APPLICATION FOR PERMIT <br /> _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y <br /> (Complete in Triplicate) <br /> Application in hereby made to San Joaquin County for a permit to construct end/or install the Mork herein described. This <br /> application is made in compliance vith San Joaquin.County Ordinance No. .549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i <br /> Job Address // Z� � _-- City Lot Size/Acreage <br /> Owner's Name ��QPL5tk� •- Address Phone <br /> - t <br /> Contractors Address I License NPhone <br /> r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Ll <br /> I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s % <br /> n Industria! ❑ Open Bottom.; ❑ Manteca �. — so. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack C1 Tracy+ Type of Casing Specifications I <br /> 1M Public': '"(1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation ,;__ Approx. Depth ❑ Eastern Surface Saul installed by <br /> I Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O s l&all Diameter Sealing Materiel i Depth I <br /> r -r Depth °t Filler Materiel & Depth <br /> TYPE OF-SEPTIC WORK: .-NEW'.INSTALLATION LJ REPAIR/ADOITION ADESTRUCTION CI INo septic system permitted if public sewer is ' <br /> available within 200 feat.] { <br /> Installation will serve: Residence _ Commercial__ Other �' � } <br /> i Number of living units: Number of bedrooms [ •-� f <br /> Character of soil to a depth of 3 feetc I ' Water table depth ` <br /> SEPTIC TANK.E,�C1 Sr❑ Type/Mfg Capacity No. Compartments <br /> ,PKG, TREATMENT PLT. ❑ '~ f ' - r Method of Disposal <br /> Distance"'to nearest: Well Foundation Property Line <br /> hLEACHING LINE No. & Length of lines „ARX29 >L!Zgb! 2 Total length/aixe } f <br /> ,,+''FILTER B'ED ❑ Distance,to nearest: Well' Foundation�a Property Line . + --r <br /> s � �F j f <br /> `SEEPAGE PITS' 11 Depth Sire` ITNumber 11 f <br /> SUMPSLI Distance to nearest: Foundation- � Property Line <br /> DISPOSAL..P„ONDS ❑ f <br /> f° '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'SSn Joaquin County <br /> Home owner or lictinsed`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 iii such manner as to become subject to workman's compensation laws of California," Contractof's hiring of 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 compensa- <br /> -'tion laws of California." i . <br /> The applicant t call for all required.in cti ns, -bm to drawing,on.riwarse-side.. <br /> SignedTitle: <br /> r <br /> R DEPARTMENT USE ONLY p { <br /> Application Accepted bycAAA Datea ` 1 Area <br /> 'N = �+ } <br /> Pit or Grout,fnapection byDatat Final Inipectio by f DataZZ <br /> Additional Comments: <br /> Applicants Return. all copies to:- SAA JOAQUIN COUNTY PUBLICtHEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> a ` ? 445 N SAH,JOAQUIN, P-O BOX 2009, STOCKTON, CA 95201 <br /> lNFEO AMOUNT DUE ;AMOUNT REMITTED CKS REC IVED 8Y DATE t jpERMIT'NO. <br /> . fH 1724 IREV. sOV / Ot% V�f�`^ / I1 <br />