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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 PA Y <br /> P O BOX 2009, STOCgTON, CA 95201 8 . . <br /> T EXPIRES FROM DATE S NOV i 1.992 <br /> j (Complete in Triplicate) <br /> Application is hereby made,to San+Joaquin County for a permit to construct and/or install the�rrbrkif}gt�ein described: This <br /> pp <br /> a lication is made in c <br /> otaplianceivith San Joaquin County Ordinance flo. 544 and 1862 and the Rules and Rb�gulations,of4�San <br /> Joaquin County Public Health Services. <br /> �} ,1 <br /> Job Address f Z, u1�J/tE4e16_+ City Lot Size/Acreage <br /> Owner's Name ' r Address`� Q , .a - _ Phone <br /> Contractor f L ".(h�e�J _Address License No. _4 2 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> + DISTANCE-TO-NEAR EST:-SEPTIC=TANK--Y *--SEWER-L-INES�----=�­-DISPOSAL FLD. �P-ROP LINE, •-� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 9 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> V) Public rl Other (l Delta Depth of Grout Seal Type of Grout <br /> i 1 Irrigalion —.Approx. Depth I I Eastern Surface Saul Installed by <br /> Repair Work Done it Type of Pump H.P.1 -- - State Wgfk Done <br /> Well Destruction ❑ Well Diameter Sealing Material R DepthA. IF ��K <br /> Depth filler Materlal i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— CommercialOther <br /> Number of living units: Num be of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK .0 Typo/Mfg 1 Capacity No. Compartments <br /> PKG. tREATMENT PLT.Cl , N. <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE ❑ No. 6 Length of linea Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I'l Depth Size Number <br /> SUMPS- 0"_—Distance to itsanst: Well -Foundation <br /> DISPOSAL PONDS PONDS ❑ l <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work tot 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 compensa- <br /> tion laws of California." <br /> The applicant must call for required inspections. Complete drawing on reverse side. <br /> Signed Title: Date:G / � <br /> R DEP rtME __USE ONLY <br /> Application Accepted by, Daterea�rl <br /> a <br /> Pk or Grout Inspection by #t� Date Final Inspection b Data/ <br /> AdditionaiComments: ! <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 H San Joaquin, P O Box 2008, Stkn, CA 95201 <br /> FEE I AMOUNT DUE AMOUNT REMITTED CK i4' <br /> INFO 'RECEIVED BY 115ATE PERMIT NO. <br /> • EH 13-14 IREV.r/e 6Mw� <br /> EH 11.26 / <br />