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APPLICATION FOR PERMIT ! <br /> { <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201. <br /> (209) 468= 7 3q--U-> <br /> REMIT MIRES 1 YEAR_ Old DATE I.5SUED <br /> (Complete in Triplicate) <br /> j • i <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 ccawliance 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 kr`r City <br /> Lot Size/Acreage <br /> Address r Q Phone�� .9s'740 <br /> r'r <br /> Owner's No <br /> o�n rac/tor SIZOZ License tic.Z�6 Phone <br /> TYPE OF WELL/PUMP'. NEW v&LLWELfREPLACEMENT n DESTRUCTION 0 Out or Service Well Cl <br /> PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER p Monitoring Well �r�f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLl7. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS1tU4PS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I�Industrial ,'�0,0tv❑ Open Bottom ❑ Manteca Oia. of Wall Excavation Dia. of Well Casing <br /> 8f <br /> U Domestic/Private ❑ Gravel Pack 'gTrocy Type of Casing Specifications <br /> M Public 34 Other ❑ Delta Depth of Grout Seat ^- 60 Type of Groufr� <br /> M IrhUation ,Approx.#Depth Eastern Surface Seal Installed by <br /> gQI--) T <br /> Repair Work Done L] Type of Pump. *1412�- H.P. State Work Done _ <br /> Weil Destruction, O Wel! Diameter Sealing Material,& Depth�4� Ai•� o- {+b�0—.;;6S'liu�+�rfSc <br /> E <br /> Depth Filler Maw rill &:Depth <br /> TYPE OF SEPTIC WORK: _NEW INSTALLATION Ll REPAIRIADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is <br /> i available within 200 feet.l <br /> Installation will serve: Residence Commercial T Other <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 4 ` Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0Method of Disposal <br /> Distance t nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 8 Length of lines Total lengthrze <br /> FILTER BED n Distance tri nearest: Well Foundation Property Line <br /> I ni <br /> I SEEPAGE PITS I I Depth t Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O st <br /> I <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 law , an <br /> i rules and regulations of the San Joaquin County <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 /> t amploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> II{ certifies the following: "I certify that in the performance of the work for which this\ermit is issued, I shall employ persons subject to workman's compenss-tion laws of California." <br /> The applicant mu 1 call f r all rs &red inspections, Complete drawing on reverse, 4 <br /> a Signad­ <br /> �� Title: Date: <br /> FORUSenelE ONLY 3 <br /> AR <br /> Application Accepted by ate ^/ Area <br /> Pit or Grout Inspection by Datel - Final Inspection by N"° -'` Date <br /> E <br /> Additional Comments: — <br /> t Applicant — Return all copies to: BAN JOAQUIN COUNTY PUBLIC HEALTH LSERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 SOX 2009, STOCKTON, CA 95201 <br /> INf <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'N0. <br /> r m � / <br /> + <br /> EH 13.71 111EV.I/HSI M M ,I - <br /> lio ` <br /> Err:�•>d _ ,� <br />