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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES1;NE <br /> ENVIRONMENTAL HEALTH DIVISION "-Ls D <br /> P`O BOX 2009 STOCgTON <br /> CA 95201 <br /> ' (209) 468-3447 <br /> ,.t <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork herein deseribed. This <br /> appllcation .1e made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regul2 <br /> 0e•of's4m <br /> Joaquin County Public Health Services. <br /> Job Address tL Zi7 <br /> ,X�p <br /> r' $.-iref' v L d City I& Lot Sime/Acreage <br /> Owner's Name A Address Phone BG <br /> l Contractor s st ` Address � S, Wif License No. ��l'q��Phone <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT DESTRUCTIONAOut of Service Well 0 <br /> PUMP INSTALLATION D SYSTEM REPAIR O� OTHER © Monitoring. Well C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM_AREA CONSTRUCTION SPECIFICATION <br /> n Industrial ❑ pan Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Cssin <br /> U Domestic/Private �ravet Pack W Tracy Typo of Casing Specifications <br /> In�Vrigation <br /> ublic 1-1 Other Cl Delta Depth of Grout Seal ` - -- Type of Grout r � <br /> —.Approx. Depth 0 Eastern Surface Seal Installed by 0 <br /> Repair Work Done U Type of Pump H.P. State Work one _ <br /> Wall Destruction O Well Diameter _ Sealing Material a Depth Q ( <br /> Depth Filler Material Z Depth r K' _ fdJ�• I a �uIC <br /> TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G No septic system permitted it public sewer is <br /> - available within 2(m teat.! <br /> Instillation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms; <br /> Character of soil to a depth of 3 feet: Water table depth V <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest- Well Foundation Property Line (O <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation - Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> I <br />� SUMPS Il .Oistance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Sen Joaquin County <br /> Home owner or licensed agent's signature certifies 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 or,to become subject to workman's Compensation laws of California."Contractors hiring or sub-contracting signature <br /> cenifIs*the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of Cali la". <br /> The applice must call f all u'sd insp®ctiona. Complete drawing on rev ss side. <br /> '� -- - Date: <br /> Signed /// Tills: 12- <br /> - -- <br /> FOR DEPARTMENT USE ONLY <br /> fes' °ee <br /> Application Accepted by _ / ._ _ Dete �" / Area <br />+ <br /> Date Final Inspection by Data Pit or Grout Inspection by <br /> - u- q/ <br /> Additional Commi n 4/- s aid; w '' o rA t e. <br /> A- --,-- rnc .b c �.� v e P�v e I'd -4Gt da ��d Su.far ce. , <br /> Applicant - Return all C4 ea to: SAN JOAWA COUNTY Pt1BLfC FI hI. ERVICES J r� <br /> ENVIRONUtNTAL HEALTH DIVISION PERMIT/SERVICES Its{-S� � 7�b 1-�/ <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95202 Ssf_62 G/ <br /> FEE ;AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT'NO. 5Y <br /> lNFQ CASH <br /> {{ <br /> r EH U-24 TREY.t�nsl !; '1 <br /> ;%•--✓J� <br /> EH 114-26 ,i"y. -°IC .. la-ao -91 Icit <br />