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M APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION ,_' <br /> t P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> (Complete in Tri.pli.cate) � P14. �j <br /> `}� , <br /> Application is hereby made,to'San Joaquin County for a permit to construct and/or install the wk, intd, Bribed. This <br /> application is made in campliance with inn Jixaquin Count, ?ordinance No. 549 and 1662 and the Rule dC'Regti tionb- of Ban <br /> Joaquin County Public Health Services .r <br /> Cyr / .._ <br /> Job Addraas J ��= / <br /> - r " r City C..A.! Lot Site/Acreage <br /> F Owner's Name LLt lIX,4472_ asdi.' yPW Address + - �- ✓D Phone <br /> Contractor Address _y License No. 21 Phone <br /> TYPE Of WELL/PUMP: NEW WELL V1kWELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK J" ___ SEWER LINES DISPOSAL FLD.I" PROP. LINE <br /> -r _FOUNDATIQ+ ._AGRICULTURE-WELD _OTHER WELL. _PITS/SUMP_S_-_,-.,.._0 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONJS <br /> 4 <br /> � <br /> ndustr;al ❑ pen Bottom ❑ Manteca Dia. of W&:Excavatio Dia. of Well Casing <br /> Domestic/Private raval Pack ❑ Tracy Type of Casing Specifications <br /> I Public ;7 I-1 0 her ❑ Delta Depth of Grout Seal Type of Grout <br /> 1:1IrnUation f( Approx. Depth Eastern Surface Seal Installed by dpi., °f <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Wait Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIR/ADDITION ZI DESTRUCTION CI (No septic system permitted if public sewer is - 4 <br /> available within 200 feet.] <br /> Installation will serve: Residence— Commercial Other <br /> Number of living unity. Number of bedrooms (� <br /> Character of soil to a depth of 3 feet: Water table depth _ 1 <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments I <br /> PKG, TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED F1 Distance to nearest: Well Foundation -,- Property Line ti <br /> } <br /> SEEPAGE PITS I I Depth $lie Number ' <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> �= --DISPOSAL PONDS C7 <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 laws, and <br /> 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 Phis 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 of sub-contracting signature <br /> certifies the following: "I certify 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 Caflfor IS." <br /> The applicant ust II for r r inspections, Complete drawing on r parse side. <br /> Signed Title: I Date: <br /> FOR DEPARTMENT USE ONLY Q <br /> Application Accepted by Data /;Z <br /> Area <br /> Pit orout nspection by Date Final,Inspection by Date <br /> Additional Comments: <br /> A licent - e�= ,;Wiee to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK AECEIVEO BY DATE PERMI7'NO. <br /> INFO CASH <br />`NEHA-24eRlV.,insr <br />}k EN 3-26 C lP l]L <br />