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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 O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT MIRES 1 YEAR FROM 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 Ban Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin Count=y Public Ham*,!tb P-rvices. <br /> c <br /> Job Addree�Y ° � * . _� Ci Lot Size/Acreage <br /> LUZAAr'l NamePhone <br /> C nt t r d �Cfi nae tko `� Phone S ✓� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT nt DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION 17 SYSTEM REPAI OTHER O - Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP: LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �.. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r� <br /> El <br /> nduatrial O Open Bottom (] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> -@omestic/Private 0Gravel Pack ❑ Tracy Type of Casing— Specifications <br /> I-I Public 'Fl Other. Fl Delta Depth of Grout Seat Type op Grout <br /> ' I I Irrigation ,; .,; ,; Approx.,pep I I E stern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work T _. <br /> Wall Destruction Well D' ter ` Sealing Materlal i Depth <br /> f <br /> Depth ! Filler Material ✓,~Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_____ Commercial_ Other ' <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 fest: Water-table depth <br /> SEPTIC TANK. O Typo/Mfg _ __ C"city No.;Compartrnents <br /> PKG. TREATMENT PLT. ❑ _ j Method of Disposal f � <br /> k 3 <br /> —Distance Distance to nearest:, Well —Foundation Property Line 1 <br /> LEACHING LINE ❑ No. i Length of linea � a f-"""Totaf'le'rig`fFi7siie 7 I <br /> FILTER BED 0 Distance to dearest:! Welt,___ ___.Foundation ' Plroperty Line <br /> SEEPAGE PITS 11 Depth ! size-___— -� t � Numlieri `• <br /> SUMPS LI Distance to nearest: Wall Foundation - Property ohs <br /> DISPOSAL PONDS 0 ! <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 Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify thai in the-performance.of the work for which this permit is issued, I shall not <br /> employ any person in such�nho become siibjeet to_workman's compensation laws of-California.' Contractor's-hiring or sub�contrecting signature <br /> certifies the following: "I co the performanceof the work for which this permit is issu d, I shall employ persons subject to workman's compensa- <br /> tion laws f C orrla." ` , 1 ' . ,aThe appli a st call for all inape ions. Comp1.1 drawing on re sa s' e. <br /> rg Title: Date: A/gs <br /> FOR DEPARTMENT USE ONLY q <br /> Application Accepted by <br /> Date <br /> res <br /> Pit or Grout Inspection by Date Final Inspection by Dat'* <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEEffINFO �AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> . EH 1tREv.ri+,so <br /> EH 141e4-M V i <br /> �I <br />