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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIROf AL HEALTH DIVIsION <br /> 1601 E- AZRE�AVE AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ��XPIRTS AR FROM �� <br /> (Complete in Triplicate) <br /> Application is hereby made to Says Joaquin County for a permit to construct and/or install the Vork herein described. This <br /> application is bade in compllence vith San Joaquin County Ordinance No, 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public H/e�alth Services. <br /> Jab Address 'r'I L L-e- Ciry fI Lot Size/Acreage <br /> Owner's Name - Address <br /> ,�} Phone <br /> Contractor Address F' v✓� <br /> TYPE OF WELL/PUMP: License No Phone <br /> NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION Q Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEP.,TIC TANK` SEWER LINES — ❑ <br /> " DISPOSAt`Ft l ' PROP. LINE <br /> FOUNDATION ^ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial 0 Open -" [] Manteca D€s. -- Well Excavation <br /> fa Domestic/Private Cl Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing Specifications <br /> I'1 Public 1-1 Other FI Delta Depth of Grout Saal <br /> I f Irrigation _ApType of Grout r_ <br /> Depth , t.l Eastern Surface Seal Installed by <br /> Repair Work Done C] Type of Pump •,� _ H.p. <br /> Well Destruction State Work Done_ <br /> O Weil Diameter Sealing !Material 4 Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I tNo septic system Permitted if public sewer is <br /> installation will serve; Residence Commercial available with€n 200 feet-} <br /> Other 2 <br /> Number of living units:___ _ Number of bedrooms,1, <br /> Character of soil to a depth of 3 feet; <br /> SEPTIC TANK. Type/Mfg --------- <br /> Witer table depth <br /> PKG. TREATMENT PLT.❑ � Capac€tyCn�,bC_ No. Compartments <br /> j f Method of Disposal <br /> Distance to nearest: Well FoundationPro <br /> �.` perty Line Q _— <br /> LEACHING LINE P No. 6 Length of lines +� r � � <br /> FILTER REDTotal length/size <br /> �l Distance to nearest: Weil` Foundation a� <br /> +.Z]�. PropeRy Line , <br /> SEEPAGE PITS I I Depth Sim t <br /> Nrmber <br /> SUMPS Distance to nearest: well400-4-- Foundation Property Line A <br /> DISPOSAL PONDS ❑ <br /> I her certify that I have prepared this application and that the work will be Ilona in accordance with S <br /> rules and regulations'of-the-San-Joan Joaquin couhty ordinances, stele laws,and <br /> atluih County—"' - ' <br /> Home owner or licensed agent's signature certifies the following: "I certify that in thetserfnrmance of the'w4rk for which this permit is issued, I shell not <br /> employ any person in such manner as to become subject IA workinan's compensation laws of California:'-Controcta <br /> 6la r s hiring or subcontracting signature <br /> 0n the following:"I certify that in the performance of the work for which this permit Is issued,I shall hFnplby persons subject to workman's cgmpenaa <br /> tion laws of California," t _ <br /> The applicant must call for all required inspections. Complete drawing on ravarsa side, <br /> Signed Title: <br /> �^ Date; <br /> Application Accepted by / o <br /> Dots i Area <br /> Ph or Groutlnspection by <br /> Date.. Finalction b-- <br /> Date} d <br /> Additional Comments: ; <br /> Applicant - Return all copies to: San Joaquin County Fublio Health <br /> Services, ]4Avlro=ontal Health Perait/Services <br /> _ 1601 h'• $aselton Ave., P 0 Boa 2009. Stockton, CA 95_201 = <br /> FEE •- - - -_- - - . - <br /> INFO MOUNT DUE— AMOUNT REMITTED CASk ~RECEIVED BY DATE <br /> F.0 <br /> Mo. <br /> .EM 19-71 fruv.rine, �+t-t O� I"��r1 v�Err a-7e y 1-• ' r l <br />