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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL`,HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application in made In compliance With San Joaquin County Ordinance No. 5 9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Ay <br /> Job Addie 6 ,A` 1 �_ City Lot Size/Acreage <br /> Owner's Nam. ' eIRCiTdress ` Phone I <br /> ConVaclor 1���� Address � �5— 1�-1.License No. Ina PhortV <br /> TYPE OF WELL/PUMP: NEIA WELL 0 _ WELL REPLACEMENT,177 'DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR 0 - OTHER 0 Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 'PROP.'LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> Jj5ffIENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing___ _ Specifications <br /> PI Public 0 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. De h, /tI Eastern Surface Seal Installed by <br /> Repair Work Done Type o W R, H.P. J State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material f Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sower is <br /> available within 200 lest.) _ <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: _ Numb r of bedrooms <br /> Character of soil to a depth of 3 fast: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments ` <br /> PKG. TREATMENT PLT.0 Method of Disposal -` <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size `f <br /> FILTER BED 0 Distance to nearest: i undation Property Line <br /> a <br /> SEEPAGE PITS 11 Depth Size Number r <br /> SUMPS LI Distance to nearest: Well Foundation Property Line f <br /> DISPOSAL PONDS 0 - <br /> I hereby certify that 1 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 /> Homeowner or li nt'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 n in such nner as to become su to workman's compensation Laws of California." Contractors hiring or sub-contracting signature <br /> certifies the aowinp: "I ce H that in mine nc of the work for which this permit is issued, I shall employ persons subject to workman's companaa <br /> tion Laws f C.lil X <br /> Thea (cant m IT: r sill r s s. C late dmwin o e/f/,/)r/�7J mid./��,/A�`A / — <br /> Signed p TitleO.S w' Date: a�..A� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by f"a,4pc�A J, S�. anr�w✓-+ Data Area�' ,Z_.T `r <br /> Pit or Grout Inspection In —^�- Date `' ' `Find Inspection by - - - Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaqulm, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13-34 NEV.IInai D 0 1 L4 C .v_ L4 lir, .. ztl e I loli- 7/i 1Q, i _ z_ / <br />