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a <br /> APPLICATION FOR PERMIT ,, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION tN O W . <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 ]\} p r <br /> PERMIT MIRES��I NAR_ ]MOM DATE ISSUE <br /> (Complete in Triplicate) <br /> Application is hereby trade 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 Health Services. <br /> Job Address CityG-r- Lot Size/Acreage <br /> R 1( Owner's Name L • " �`s Address Dom`' `' �`�Q Phone r r <br /> K Contractor �w Jr' r� _ Address 54'/1L� _ _ —License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ of Service Well Ll <br /> PUMP INSTA ION 0 SYSTEM REPAIR ❑ OT p Monitoring Well �� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F . PROP. LINE <br /> FDUN ATION A ULTURE WELL OT ELL" PITS/SUMPS <br /> 0NTENDED USE TYPE OF WELL PROBLEM AREA u T.. STRUCT PECIFICATIONS <br /> fl dustria[ ❑ Ops Bottom ❑ Manteca Dia. Excavation Dia. of Well Casing <br /> U omsaticlPrivats ❑ Gra I Pack ❑ Tracy ype of Casing-° - Specifications <br /> * ttblie C Oth ❑ D Depth of Grout Seal Type of Grout <br /> * igation prox, Dep Eastern Surface Seat installed by <br /> Rep it Work Done 0 7 H.P. State Work D <br /> Wd Destruction © II D meter Sealing liaterial i Depth <br /> pth <br /> TVP. OF SEPTIC WORK: EW STALLATIO REPAIR/ADDITION Ll DESTRUCTI INo septic system permitted if public sewer is <br /> available within 200 lost.) <br /> In fellation will serve: R iden Yl Com er ia[.—..,. Other J <br /> Nimber of living units: Number of be r ms ~ <br /> I C ratter of soil to a dept of 3 fee[: Water table p <br /> SEP IC TANK ❑ T /Mfg Capacity No. Compan nts <br /> PKG TREATMENT PLT. ❑ Method of D o 0 <br /> Dist Ince to neares Well foundation. Property Line -Tot <br /> LEACHING LINE C3 No. Length'of li s c al,length/size <br /> FIL R BED n Dist ce to neares Well Fon tion Property Line <br /> . E <br /> r SEE AGE PITS 11 Dep { Si:e tuber <br /> SU PS Ll Dist ce to nearest j Well Foundation Property Line <br /> DIS OSAL PONDS ❑ <br /> ! ha by certify that I have p spar this appGcati n nd that the work will be done in accord ce with San Joaquin county ordinances, state laws, and <br /> rule and regulations of the an J quip County <br /> Ho owner or licensed age is sig ature cemifie t a following,"I certify that in the perform ca of the work for which this permit is issued. I shall not <br /> amp Dy any person in such nner s to become ect to workman's compensation laws of lifornia." Contractor's hiring or sub-contracting signature <br /> cerci ies the following; "I cart"y th t n the partor a of the work for which this permit is issu I shall employ persons subject to workman's cornpenss- <br /> �on aws of California." /� <br /> �he pplicant must call for a req i ad insp®ction . amplete drawing on reverse side. c� <br /> X <br /> Sigr od TSR Date: <br /> VDEPARTMENT USE ONLY <br /> t� <br /> pp cation"Accepted by V &MA Date Area <br /> t Grout Inspection by " Date Final Inspection b Date <br /> dd Iona[ Comments. <br /> ,�*pp scant - Return all pie to: SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 445 N So JOAQUIN.—P O BQI 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT�E If *ED CASH RECEIVED 8Y rDDATE�j PEBM17LNO. <br /> � <br /> 7T0� Y, a-b 13z_5 <br />