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APPLICATION FOR MMIT <br /> SAN JOAQUIN COuiTf PUBLIC HEALTH SERVICES <br /> IMIRONUMTAL HEALTH DIVISION <br /> 445_ N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> YM xam D= IQ§UED— SCONED <br /> (Complete in Triplicate) <br /> Anlisation is hereby wade.to 8" Joaquin Vountp for a permit to coatstruat a:nd/or install the work herein described. This <br /> awliestion 3a made in t:0q?l1 _with San Joaquin County Ordinance No. 549 and. I8Q and the Rules and Regu)Atiotm of San <br /> Jaagniti COWA*;Rab3:ie Saltit 8er�rices. /w/V.c '5—i 70 - <br /> City L Lot Size/Acreage <br /> Job Address <br /> 4 <br /> Phone <br /> Owner <br /> 's Nems <br /> Address <br />� <br /> Contractor Address License No.—Phone <br /> TYPE OF WELLIPUMP: NEW WELL WELL REPLACE ENT 0 DESTRUET10N ❑ Out ofr*e toring WO-11well 0 <br /> PUMP iNSTALLATLON © SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL.FLD.Z PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECN4CATIONSF7r IQ <br /> �. <br /> I 0 Industrial ❑Open Bottom ❑ Manteca . Dia. of WOO Excavatlon. Dia. of Well CasingJ <br /> n Domestic/Private 1K Gravel Pack Tracy Type of Casing— <br /> of <br /> asing 5pecificatiorss <br /> 11 Public n Other n Delta Depth of Grout Seat Type <br /> r [1 <br /> Irrigatia, Apprgx: Depth t 1 Eastam Surface 5sel Installed by - -- - •f <br />` Repair Work Done 0 lype of Pump H.P. Stag Work Done <br /> Well Destruction © WOO Diameter sealin6 Material E Depth - AJ <br /> Depth >fill,er Itatasial i neptix <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 AEPAIRiADDITION I I DESTRUCTION I I IN*septic system pammusd if public sewer is <br /> available within 200 feet.1 <br /> Installation w4I same: .Reiidenoa_ Commercial— Other 4 <br /> Nanew of Oving units: Nuadw of bedmon-4 (PAYMENT � <br /> Characw of soft to a depth of 3 fast: Water P <br /> SEPTIC TANK. . ❑ Type/Mfg Capacity No.Cor r �C <br /> PKG.TREATMENT PLT.© �7 <br /> Distance to nearest: Well Foundation Property. fiQ1,.N Y <br /> LEACHING LINE Cl No. B Length of lines Totat length <br /> FILTER BEA - O Distance to ravest: Wa# Foundation Property Line <br /> SEEPAGE PITS l I Depth Sirs Number <br /> SUMPS Irl Distanoe to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby Certify that I have prepared this application and that the work will be done in accordance with Son Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed 49ant's iignaturs certif es the foliowing: -I certify that in the performance of the work for which this permit is issued, I shall not <br /> ompl*y any person in such m wvw as to become subject to workman's compensation laws of California."Contractor's hiring of tub-contracting siggatura <br /> Certifies tits fo%owirtg:"t certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's componss- <br /> lion laves of Camornls." <br /> The"OWret callfor sty requirtions. C to drawing on rao_sicle <br /> S�Md11 —0 Thi Date: <br /> DEPA ENT USE ONLY <br /> I Date g' Ares <br /> Application Accepted by <br /> PH or Grout Inaprctlon by Date Final Irtspectkut by D <br /> NI Additional Conwwrts: <br /> F Applicant - Return all copiers to: San Joaquin County Public Health Services <br /> i Ssvirozaeeatal Bealth Permit/Services <br /> 445 N Sag Joaquin, 0 Box 3009, Stka, CA 95201 <br /> a <br /> FW FEE AMOUNT DUE AMOUNT REMITTED RECEIVOI)BY DATE PERMIT'NO. <br /> PIG <br /> . EH Ixt1 tnEv.Iia 61 swz �!�.' � 6!� rr7 —&o <br /> .- <br /> E►r 14-30 <br />