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APPLICATION FOR PERMIT <br /> rY,+.•v,� _ JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �� ENVIRONMENTAL HEALTH DIVISION <br /> t <br /> 9;TCPJ1VfiP0D BOX 2009 STOCKTON, CA 95201 <br /> P 0 8 1992 (209) 468-3447 � <br /> i SAN JCj,••ti(,ii.i11.q Cfyp <br /> °iE:RVICCS <br /> (Complete in Triplicate) <br /> c!'!'tl1F1(}fVf;r1EP!'f�i f �T � ,r. ,.�� i <br /> Applieatioa is hereby made to tidd`�oa+��4�l+I&Wmty far a permit to construct and/or install the work herein described. This <br /> application is each in Co4liance with San Joaquin County Ordinance Ho, 549 and 1852 and the Rules and Regulations or San <br /> Joagala County Public Health Services. <br /> Job Addres4lQI-S 0 SO City at Site/Acreage <br /> ',.. owner's Mama _Address Phone <br /> Coni rac re S4 ho, Phon <br /> TYPE F WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 <br /> DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION Zl- SYSTEM REPAIR OTHER O Monitoring Well ''• <br /> C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ _ _ SEWER LINES DISPOSAL FLD, , PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PR08LEM AREACONSTRUCTION SPECIFICATIONS 2 <br /> f.1 1 d��a�1— ❑ Open— Bottom p Manteca R Dia, of Well Excavation pia, of Weil Casing <br /> fD�Domestielprivate O Gravel Pack 0 Tracy Type of Caring . Spacilications_. <br /> C1 Publlo C1 Other ❑ Delta Depth of Grout Seal Type of Group <br /> ...a P Irn anon _ . <br /> U APprgx, Depth Errtern Surf lice Soul Installed by <br /> Repair Work Done � Type of Pump�'.. H,P. _ _ State Work Done 00 X <br /> Well Datruetfon ❑ Well Diameter ��. sealing Material i Depth t . <br /> Depth Tiller Material i Depth r N <br /> A <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 RE PAIR lADOITION M DESTRUCTION EJ INo septic System permitted if public sewer is r� <br /> i <br /> Instellstlon will serve: Residence Commercial, Other available within BOO feet.l r} <br /> O !� <br /> Number of living units: Number of bedrooms ' <br /> Character of saN to.depth of 3 feet; � E <br /> SEPTIC TANK. ❑ Type/Mfg Water table depth <br /> Capacfty� No. Compartments t <br /> PKG. TREATMENT PLT.❑ <br /> Method a1 Disposal <br /> Distance to nearest: Wall Foundation Property Una <br /> :? <br /> } LEACHING LINE Cl No. 8 Length of lines <br /> FILTER BEDTotal length/size <br /> CI Distance to neareal., WOU Foundation �_ Property Line <br /> SEEPAGE PITS <br /> 11 Depth _ Size Number <br /> SUMPS LI Distance to neareek Wellk <br /> DISPOSAL PONDS ❑ Foundation _ - Property Line <br /> I hereby certify that I have prepared Ihii application and that the work will be done in accordance <br /> rules and regulations of the San Joaquin County with San Joaquin county ordinances, slate laws, and' J <br /> -i <br /> Home owner or licsnard agent's signature certifies the following: "I cerlity that In the performance of the work for which this permit is issued. I shell not <br /> employ Arty person in Such Hunner as to became subject to workmen's compenseIion laws of California,"Contractor's hiring or sub-contracting signature <br /> esrtifiss the following:"I certify$hat in the performance of the work for which this permit is issued, (shall employ persons subject to workman's compensa• <br /> tion laws of Calefornia." <br /> The applicant mw for ell required JlAsP9,clions. Complete drawing on r rse side. <br /> 1 Signed <br /> Tltia• Data: <br /> FOR DEPARTMENT USE ONLY <br /> j Apolkatlon Accepted by <br /> Dote Area <br /> Pit or Grout Inspection by Data �= <br /> -•--�.� Final Inspection by Date <br /> Additional Comments: "1 <br /> Applicant - Return all 000188 tot BAN JOAQUIN COUNTY PUBLIC HSALTI1 SERVICES I" <br /> ENVIRONMENTAL, HEALTH DIVI9101f pERIl1T/STRVICES <br /> i 445 N sAN JOAgUIN, P O BOK 2009, STOCKTON, CA 95201 <br /> FEE MOUNT DUE <br /> INFO <br /> AAMOUNT I3EMIT7E0 RECEIVER liY <br /> j Ek a DIAOTE PE3RMIT�'�tto111 SC0 lT. &a) <br /> j <br /> } <br /> . 1 <br />