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�• c n <br /> b ti <br /> APPLICATION XOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PMIT EXPIRES1 YEAR R M DAT_E_1§_SMM <br /> (Complete in Triplicate) <br /> Application is hereby made to Ban 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 /> 1 City Lot Size/Acreage <br /> Job Address 'i� 1 Q 7 <br /> e Phone `& — � 1 <br /> W is Name D j , -- <br /> s <br /> No r 6J Phone <br /> C or _r ✓ �3`� <br /> TYPE OF WELL/PUMP: �; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll of Service Well ❑ <br /> ��`` Flonitoring well ❑ <br /> PUMP INSTALLATION• SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED.USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing <br /> ;L-Jnduatrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation <br /> Specifications <br /> Type of Casinomestic/Private ❑ Gravel Pack ❑ Tracy 9Type of Grout <br /> 1 Public I-1 Other n Delta epth of Grout Seal <br /> 1 1 Irrigation _Approx. Depth I I Eastern `� urfoce Seal Installed by <br /> Repair Work Done U Type of Pump H.P" Stata Work Donll <br /> Sealing Pfaterial i Depth <br /> Well Destruction ❑ Welt Dia i t�teer <br /> ' ^ <br /> Fll <br /> Depth ier Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ISI REPAI /ADDITION I ly DESTRUCTION I i INo septic system permitted it public severer is <br /> i available within 200 feet.l <br /> Installation will serve: Residence Commercials A Other <br /> Number of living units: Number of bedrooms <br />` Water table depth <br /> Character of soll to a depth of 3 feet: I <br /> K` ❑ T dMfg Cipacity No. Compartments <br /> SEPTIC TAN Vpo <br /> PKG. TREATMENT PLT. ❑ F Method of Disposal <br /> Distance to nearest: WallI ;-Foundation,�,�.Property Line <br /> LEACHING LINE 0 No. & Length of lines r i Total length/sire <br /> FILTER BED 1 ❑ Distance to nearest: Well Fou dalion Property Line <br /> } <br /> Number -- <br /> SEEPAGE P{T$�1_11 Depth Sire <br /> SUMPS I LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I I hereby csnify 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: "! certify that in the performance of the work for which this permit is issued, k shall not <br /> employ any parson in suc manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contrscting signature <br /> unifies the fohbwing:'•1 s 'fy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cold Is., <br /> The applica4 call f Mi ired 1 speotions. Complete drawing on to se side. d <br /> Signed' Title: <br /> Date: <br /> _ FQR DEPARTMENT USE ONLY <br /> IDate ` �' Area 2 <br /> Application Acdapted by <br /> Pit or Grout inspection by <br /> Date Find Inspection by Data <br /> Additional Co`mmonts: <br /> Applicant _ Return all copies to: San Joaquin County Public Health Services ,n <br /> I Environmental Health Permit/Services <br /> F 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOVNT DtIE AMOUNT REMITTED C% RECEIVED By DATE PERMIT`NO. <br /> INFO f� (�C�AyS�H00 <br /> HQ <br /> . EM 1b21 IRtY.I/ r \ r �-� `� -� Ld`v <br /> EN 11.18 1 <br />