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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> P IT EXPIRES_ X YEAR PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mads 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 end 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Narn t T_ A1C4 - Address [ ._ Phone <br /> ; <br /> Contractor fsta4E Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER O Monitoring Well C7 i <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 x `' <br /> •Cl Industrial 0 Open Bottom 0 Manteca Die. of Well Excavation � is, of Well Casing <br /> CJ Domestic/Private -Cl Gravel Pack C7 Tracy Type of Casing Specifications <br /> 0 Public 1-1 Other © Delta Depth of Grout Seal ` Type of Grout <br /> M Ifrioation ❑ Eastern Surface Seul Installed by <br /> Repair Work Done LJ Type of Pump N.P. State Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Material i Depth. <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION R:�� <br /> DITION Cl DESTRUCTION.0 (No septic system permitted if public sewer is 1 <br /> available within 200 teat) i <br /> Installation will serve: Residence .� Commercial T <br /> Number of Irving.unils: Number of adrooms <br /> Character of wit to a depth of 3 feet: Water table depth Q <br /> SEPTIC TANK O Type/Mfg L Capacity 1_242122> Compartments —� <br /> PKG. TREATMENT PLT.Cl t Method of Disposal <br /> Distance to nearest: Well Foundation PropertyLine <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size d C1 ! <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line/� <br /> + I <br /> SEEPAGE PITS 11 Depth Size AK/O '�>f � �__ Number <br /> 4 . <br /> SUMPS Cl Distance to nearest: Well 2Foundation ei`n Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin couniy ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies 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 sub-contracting signature <br /> certifies the following; "I certify that in the performance of the work tot which this permit is issued, E shall employ persons subject to workman's componsa- <br /> tion laws of California." <br /> The applicant hust tali f I required inspections. Complete drawing on reverse side. <br /> Signed Title: ._ Date: I <br /> F R D PARTENT VSE ONLY <br /> Application Accepted by Date <br /> Pit or Grout Inspection by NDate Final Inspection by Data <br /> Additional Comments: �` � ��/� �'��� �fc f �1#Il /��r <br /> Applicant - Return copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 11 <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 495 N SAN JOAQUIN, P O 80 Ola, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE OUNT AEMrTTED K H RECEIVED BY DATE PERMITNo. <br /> . EH17.24IpEV.+i"S) IZ-4 / Qq- .� ' L(J 1a��J f <br /> EH 31.2e 11�� <br />