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{ ' K. APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC <br /> ENVIRONMENTAL HEALTH DIVISION 'RECENtu <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 0 CT 1 8 1990 <br /> PERMrT EXPIRIs'S 1 YEAR rRQX .PATE Lia& IVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMIT/SERVICES <br /> ,7- Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> 3 application is made in ccvpliance.with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> .: Joaquin County Public Health Services. <br /> 117 <br /> Job Address d W. City Lot Size/Acreage <br /> 1 <br /> Owner's Name AddressPhone <br /> Contractor�>¢�cas���r� __ Addressph Q1(n_ jjda .al lf_9�t License Phone �1 <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well L7 <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 /> n Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D QomesticlPrivate ❑ Gravel Pack n Tracy Type of Casing Specifications <br /> Z) Public is Other 0 Delta Depth of Grout Seal Type of Grout <br /> l 0 Irfi ation A rox. Depth ❑ Eastern Surface Seal Installed b <br /> r � U �., pp 5 P e � Y <br /> Repair Work Done Type of Pump� H.P. -Z __ State Work Done <br /> Walt Destruction O Well Diameterpp Sealing AUiial.i Depth <br /> Depth 1 Filler Material.,i.Depth' . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION_Cl:(No septic system permitted if public sewer is <br /> available within 200 feet.i <br /> 1 Installation will serve: Residence Commercial— -Other A <br /> r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ---- ❑--Type/Mfg= Capacity No. Compartments <br /> _. PKG. TREATMENT PLT:Cl # Method of Disposal <br /> Distance I nearest: Well Foundation Praperty Line <br /> LEACHING LINE ❑ No. & Leneth of lined Total length/size <br /> FILTER BED n Distance to ries est:; ' Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth S Number <br /> SUMPS _ .Ll_ ..Distance.to_nearest:_,wWolf---- .,.Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work Lwill 6e,done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations.of the San Joaquin4lCounty ,l <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for 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 subcontracting signature <br /> certifies the following: "I certify that in tha.performance of the work for which this permit is issued, !shall employ persons subject to workman's Componsa- <br /> tion Isws of 6146rnla", # <br /> The applicant must call f II required inspections, Complete drawing on reverse side. <br /> Q o <br /> Sign Title: �_1�- , �« �T Date: !�_ L--'_ !iQ <br /> R DEPARTMENT USE ONLY ✓ .� A <br /> Application Accepted by Date 4 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: _ <br /> Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> (ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAH JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT FiEMITTEDt CASH RECE11 IVED 9Y DATE PfRMI�I/NO. <br /> + EH13-241REY,I/h5! !� r , , , JID—I�-Q <br /> EH 74.20 <br />