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I <br /> APPLICATION FOR PERMIT <br />` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Sr <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 9520 . ,�� <br /> (209) 468-3447 <br /> R `Z1L- <br /> (Complete in Triplicate) <br /> Application is hereby made to San`Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application Is made in cattepliancf�� <br /> e,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 <br /> City ,. �--�/� <br /> tY--�.�±- /V Lot Size/Acreage <br /> _ Qwner's NamedressJ <br /> • Contractor I._. Ad ��• Phonxx <br /> Address "AA� License N Phon <br /> TYPE OF WELL/PUMP: � Ll <br /> NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well 03 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ Moni;tori4 well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE�� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPEi.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> Cl Industrial ❑ Operi� Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private C1 Grev91 'P&,** Cl-Tracy - --Type of-Geeing Specifications I <br /> Cl Public Ci IOthei t. ' ❑ Delta Depth of Grout Seal - Type of Grout 1 <br /> G 1rn0ation .Approxi Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump r -H.P <br /> State Work Dona <br /> Well Destruction O Well Diameter Sealing Material II: Depth <br /> Depth f * Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTAI:LATION L7 ti- REPAIR/ADDITION M DESTRUCTION INo_lseptic system permitted if public sewer is <br /> available within 200,feet.l i <br /> installation will serve: Residence- ++_-Commercial 4 Other �� t 3 <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth'of 3 feet: f <br /> Water table d4pth <br /> SEPTIC TANK. �FType/Mfg 1 Ca cit ! <br /> PKG. TREATMENT PLT. C) Y o. Compartments <br /> 1 r. Method of Disposal <br /> pr <br /> Distance to nearest: Well Foundations ; vw, Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED IM Distance to nearest: .,,Well i Foundation <br /> Property Lina <br /> SEEPAGE PITS 11 Depth Size <br /> SUMPS Number <br /> Ll 'Oistanca to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ! -�---- <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 San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in thethispermit } <br /> shall not <br /> employ any person in such manner as to become subject to workman's compensation laweoof California." Contractors hiring pr sub-contractingis issued, lsignature <br /> certifies the following: "I certify that in the performance of the=work for-whichi.fhis ermi14*issued, f shalfem to g" <br /> tion laws of California." sp P Y per'sonsatubject to workman's compenaa- <br /> The applicant must I for al ',squired inspect' Complete drawing on reverse side. <br /> ` t <br /> Signed Titl <br /> FC&DEPARTMENT USE ONLY <br /> Application Accepted by v <br /> r Area <br /> Pit or Grout Inspection by i <br /> Date _ Final Inspection by > Date -7 <br /> Additional Comments: <br /> APPlicaAt - Return all co ee to: Q <br /> P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECOV.Eo BY afE <br /> 1 ����+�(**�� // f�f� PERMIT'NO. r <br />• EH14•7{Il1EV.1/M51 L4�L .� Ol1� <br /> EH:!•je L.7 <br /> 9I l.. � <br />