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it <br /> " APPLICATION FOR PERMIT <br /> II SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIR0NI[ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> illi �+ <br /> Job Address ��� �- TC �- Cityn'R �QF.� lot Size/Acreage <br /> Owner's Name <br /> �.]��V��� �� _ Address.- Phone Q&-&`1� <br /> _ _ <br /> Contractor �UVVN AddressV License No. Phone � " Q <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELD OTHER WELL PITS/SUMPS . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^ <br /> Cl Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing n` <br /> +Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> 1.1 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Deepth' �I I Eastern Surface Seal Installed by <br /> Repair Work Done U Typsiof Pump , 'Z!y H.P. 3 State Work Done rl'61gQ- C-'R <br /> Well Destruction 0 well Diameter Sealing Material A Depth <br /> Depth biller Material:i.Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIAIADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> 9� <br /> Number of living units: Number of bedrooms + <br /> f Character of soli to a depth of+3 feet: 4' T --_ '' ` F1l1ia[er table depth <br /> %S£PTIC�7ANK. D Tye/Mill ;- r� y_ Capacity `` =No'Compartments <br />" PKG. TREATMENT PLT. ❑ Method of Disposal <br /> f Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I : Depth Size Number <br /> T T SUMPS L) Distance to nearest: Well r `� Foundi floif f JPropertV Line <br /> ^DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepiired 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 /> �.._m - .. <br /> Home owner or lids_nsad agent'a ognalure cinifiei the following;"I.eertity that in the performance of the work for._which this permit is issued. I shell not <br /> empioy any person.in such manner as to become subject to work`man's compentiation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following-'1 certify that in the performance of tKa wqk for which thislpermit.ia issued, I-shall employ persons subject to workman's compensa- <br /> tion laws of California,” <br /> Thea <br /> pplicant�musi call for aN required inspsctionf:Complete drawin on reverse side. <br /> Signed X-_ }- Titles~.- Date: <br /> FOSEPARTMENT USE ONLY <br /> Application Accepted by Datef Ata <br />+ Pit or Grout Inspection by II Data Final Inspection b Datp� <br /> Additional Comments: <br /> �i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2008, Stkn, CA 95201 <br /> N E A OUNT DUE AMOUNT REMITTE _ CK �'F.F R EIVED BY DAT PERMIT'NO. <br /> L-51 EM 1,7.74 t11t:y <br /> EN 14•Ia <br /> II <br />