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,. APPLICATION FOR,,PERUIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEwICTS <br /> ENVIRONMENTAL HEALTH -DIVISION <br /> . :P O BOX 2009, STOCKTON, - CA 95201 <br /> (209) - 468--3447,3;1---)-0 <br /> REMIT EXPIRES i YEARJROGd `:DATE I UEp .W <br /> (Complete' .in Triplicate) _ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork -herein described. This <br /> application is made in comilia.nce with San Joaquin County Ordinance No. 549 and,1$62 and the Rules aszd-Aegulstions of San <br /> Joaquin County Public Health Services. <br /> Jab Address L T it ��.City t Lot Size/Acreage <br /> Owner's Name 'v' '� Address 1RfZ€�" "I Phona <br /> Contractor✓U !� `�Address ��� Z�� License No� Op�y; 3 ^ Phone �� �'� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION;',❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEWREPAIR C•Y�` OTHER"❑ ,.Monitoring Well. <br /> DISTANCE~TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.. LINE - <br /> ti. FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS <br /> f_1 industrial ❑ Open Bottom ❑ Manteca Oia. of Well Excavation roDia. of Well Casing t + <br /> U Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications r <br /> M Public I:1 Other ❑ Delta Depth of Grout Seal Typo of Grout <br /> G lirigation —Approx. Depth ❑ Eastern Surface Seal Installed by e <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Wall Destruction ❑ Well Diameter Sealing Material 'i Depth' <br /> r <br /> Depth Filler Material L Depth .� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ID AEPAIRIADDITION M DESTRUCTION fJ tNo septic systemllpermitted if public sewer is <br /> available within 200 feei.l <br /> Installation will serve: Residence_ Commercial Other. n <br /> a. <br /> Number of living units: Number of bedrooms -- <br /> Character of soil to a depth of 3 feet: " Water table depth:'' <br /> r SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.1:1 , i.;.5. Method of Disposal <br /> �II <br /> Distance to nearest:- Well "' Foundaabn Property Line ^C <br /> LEACHING LINE C1No. & Length of line; Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation' ` Property Line ai ' <br /> -.SEEPAGE PITS f I Depth Sire Number r <br /> SUMPS LI Distance to nearest: Well Foundation Property Bina <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sam Joaquin county ordinances, state laws, and <br /> rules and reg tions of the San Joaquin County ` <br /> Home owner or 'cans:. agent's signature certifies the following:"'I certify that in the perlormance.of the work for which this.permit is issued, I shall not <br /> employ anyW <br /> r as to bec s subject to workman's compensation laws of California:" Contractor's hiring or sub contracting signaturecertifies theint rf ,mance f the work for which this permit is issued; l shall employ persons subject to workman's compensa <br /> tion Eaws ofThe appltcauired 'ns io C plate drawing on�reve s side. <br /> Signed X. Title: C �- Date: <br /> FOA DEPARTMENT USE ONLY <br /> 91 <br /> Application Accepted by , <br /> Date —Z N Area <br /> Pit or Grout Inspection by Date Final Inspection by mv DateV. <br /> '( i <br /> Additional Comments: <br /> Applicant — Return all copies to: SAN JOAQUIN COUNTY:PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ` r <br /> 445 N SAN JOAQUIN,' P O BOX 2009, STOCKTON, CA 95201 <br /> fEE AMOUNT DUE AMOUNT REMITTED CASH ECEIVED 9Y _ OATS- PERMIT NO. R <br /> INFO <br /> . EH 13.24IAEV.I/As) ✓.V l..J �-L 9) g�"*�!/� <br /> EM :4.20 _ - 2 <br /> a :p ii <br />