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�1 <br /> APPLICATION FOR PERMIT q <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOB 2009s STOCK ON, CA 95201 <br /> (209) 468-96-'7 3q- p <br /> Y R <br /> (Complete is Triplicate) <br /> F <br /> made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> Application is hereby meld.• uin County Ordinance No. 51+9 and 1862 and the Rules and Relations of San <br /> application is made in caaopliance with San Joan <br /> Joaquin County Public Health Services. <br /> _ City <br /> Lot Site/Acreage <br /> �( <br /> Job Address •' r <br /> 2�i,•L�i C' Lo�. d Phone <br /> Ric-- <br /> `_�� �r,L Address ! <br /> Owner's Name , g 7 <br /> Servii:e Well <br /> ��E�B � License No. ' 71' Phone <br /> �`� <br /> K • ��yl�--� IMf Address 7 <br /> NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out ot� <br /> Contractor 7 <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR O <br /> OTHER D Monitoring Well <br /> PUMP INSTALLATION O DISPOSAL fLD. PROP. LINT <br /> OTHER WELL --- <br /> SEWER LINES _ p1T5/SUfv1PS ...._ <br /> DISTANCE TOAGRICUL <br /> .NEAREST: SEPTIC TANK TURE WELL ( , <br /> FOUNDATION <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �• <br /> INTENDED USE Dia. of Well Casing J <br /> p gpen Bottom D Manteca D'ia. of Well Excavation <br /> n Industrial Type of Casing Specifications <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grollt <br /> M Public 1:1 Other ❑ Delta , <br /> 11 .Approx. Depth ❑ Eastern <br /> Repair Work Done U Type of Pump Surface Seal Installed by <br /> C! IrriOation 11 State Work Done _ <br /> �.� H.P. $ <br /> t Sealing material 4 Depth , <br /> Well Destruction D W4iN Diameter �— <br /> II Filler Material fr Depth <br /> Depth <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Cl DES TRUCTION CI alloilqo abPrrwlthi71 �e200 teeth{/edtfpubfie sewer i <br /> Installation will serve: Residl once— Commercial Zother <br /> Number of living units: !M Number of bedrooms <br /> Water table depth <br /> Character of soil to a deptof3 feet: No. Compartments <br /> SEPTIC TANK- D Type/Mfg Capacity._ -- <br /> Method of Disposal <br /> PKG. TREATMENT PLT.D � � Property Line <br /> Distance to nearest: Well Foundation li <br /> LEACHING LINE ❑ No. 6 Length of lines <br /> Property line <br /> Total length/sire <br /> FILTER BED i::1 i Distance to nearest: Well Foundation�— M <br /> SEEPAGE PITS ( I , Depth Sixe Number q <br /> SUMPS L1 Distance to nearest: Well Foundation <br /> Property Line ,f" <br /> DISPOSAL PONDS ❑ <br /> will be done in accordance with San Joaquin county ordinances, state Jaws, and <br /> I hereby certify that 1 have prepared this application and that the work <br /> f rules and regulations of the San Joaquin county <br /> Home owner or licensed agent's signature certifies themploy pe following: "I Certify that in the performance of the work for which this pemit is issued, I shall not <br /> uch m6nner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature <br /> employ any person in s <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall arsons subject to workman's compensa <br /> tion taws of California." ��I II '. <br /> The applicant must call for a required inspections. Complete drawing on rexerse side. <br /> 1Signed LCL – Title: Date: 1 <br /> R DEPARTMENT E ONLY%I1 0 <br /> i <br /> • Date A Area <br /> Application Accepted by <br /> Date Final Inspection b Dats <br /> Pit or Grout Inspection by it <br /> IL <br /> Additional Comments: E <br /> Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O SOX 2000, STOCKTON, CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'N0. <br /> AMOUNT DUE AMOUNT REMITTED CASH / <br /> . EK 1124 tFIEV.I/it INFO l " R LI Jb r �t ? -el [L U-T <br /> EH 14.2a • <br />