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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made In coupllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> Lot Size/Acreage <br /> Job Address - `��` <br /> Owner's Name <br /> N\V%%.via _ Address +� Phone <br /> Contracts <br /> Address `` License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ W�11PLACEMENT DESTRUCTION Ll of novservice Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C7 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Specifications <br /> [.I Domestic/PFIVata ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> I'1 Public 1-1 Other n Delia Depth of Grout Seal <br /> Type of Grout <br /> Peirrigation _Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Sealing Material Depth (� <br /> WaitDestruction O Wall Diameter Tiller Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIO DE RUCTION I I INsilabptic system <br /> shin 200 feet.) it public sewer is <br /> Installation will serve: Residence— Commercisi_ Ot <br /> Number of living units: Number of rooms <br /> Water table depth <br /> Character of SON to a depth of 3 feet: <br /> SEPTIC TANK.' O Typo/Mfg C city No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nos rb t: 6 Found Ion Property Lino <br /> LEACHING LINE ❑ No. b Length of 11nes Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel F ndstion Propeny Line O <br /> SEEPAGE PITS 11 Depth '��11° <br /> Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> that the work will be done in accordance with San Joaquin county ordinirSoBi;>ltats laws, and <br /> I hereby certify that I have prepared this application and <br /> rules and regulations of the Son Joaquin County <br /> flowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Horne owner or licensed agent's signature certifies the lo <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." ` <br /> The applicant must CaN for all required inspections. Co`mpletb drewin on reverse si/de`. Q 1 t� Date: `� <br /> Sipped <br /> `cY\��� ��\�.�►`c Titley <br /> FORD ARTMENT USE ONLY <br /> Are <br /> Application Accepted by <br /> Date Z h <br /> PN or Grout Inspection by Date Final Inspection b Dat;Ae <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> ZFEK RECEIVED gY DATE PERMIT'NO. <br /> A OMDUEAMOUNT REMITTED EH 13-24 IIIEV.1 6 <br /> EH 11.11 <br />