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4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL, HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> FZA11[IT .EXPIRES I YEAR--- PROM--DATETSSUZn <br /> I (Complete in Triplicate) <br /> I <br /> Application is hereby >aade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made iu'COVliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> k Joaquin County PPubblle.Health Services. <br /> - <br /> Job Address <br /> k _ City Lot Size/Acreage <br /> Owner's Name-all Address C3 CO s� <br /> .. �-S ��Phone <br /> contra re License 4d. O !F46'2— <br /> TYPE <br /> a�Pho ! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WEiL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> ..Y PUMP INSTALLATION ❑ . . SYSTEM REPAIR. Monitor; Well i7 <br /> �-. _.. �,_ _t �.�_ OTHER ❑_ n6 <br />€ DISTANCE TO NEAREST; SEPTIC TANK 5EWER LINES DISPOSAL FLD. PROP. LINEM <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f-1 a1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Mic/Private C] Gravel Pack 0 Tracy Type of Casing Specifications <br /> MPublic (7 Other I IJDelta Depth of Grout Seal Type of Grout q 1 <br /> C� Inipation Approx'bepth ❑ Eastern P Surface Seal Installed by <br /> Repair Work Done I.— Type of Pump H,P, ��� State Work Done �J <br /> Well Destruction ❑ Well Diameter Se ing Material ; Depth <br /> Depth r Filler Material & Depth a <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION Ll REPAIR/ADDITION L7 DESTRUCTION G fNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Inst►%allation w)U serve; Residence_ Commercial_ Other <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feel: <br /> ...t <br /> SEPTIC TANK. ) Water table depth <br /> ❑ T <br /> �F* <br /> - ype/Mfg s <br /> PKG. TREATMENT PLT. ❑ Ca'pacitY— No. Compartments <br /> Method x.5�, ��� � � -- <br /> 1 ' pns fTal <br /> Distance to nearest:"` ' Well� Foundation proeE <br /> LEACHING LINE Ll No. & Length of lines { Total nlength/! '� <br /> FILTER BED Distance to nearest: Wel) I^- --Foundation--- -- <br /> ) Propb�y Lin <br /> II C,01-)`NTY---- , <br /> SEEPAGE PITS I I Depth I Sire Numb�ti �IC"F�EAL 5c ' <br />--i--- Sumps ���:,:."A�,.LI—Distance-to-nearest:= Well s�.... Foundation; EIV <br /> IL the <br /> H n <br /> _ Ir <br /> DISPOSAL PONDS ❑ -~_-- - - .� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San di <br /> nty ordinances,,state laws, and j <br /> rules and regulations of the San Joaquin County i Joaquin cpud <br /> Home owner or licensed agent's signature certifies the followings "I'certify that in the performance of the work for which this permit is issued, f shall not d <br /> employ any person in such manner as to become subject to workman's compensation laws of Calilornia." Contractor's hiring or sub-contracting 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 rgt. call 1 quired inspocticos. Complete drawing on to side. <br /> C/ <br /> Signed Q <br /> Title: D., Date• '" <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate 7 ,1 Z � �•� <br /> -A res <br /> Pit or Grout Inspection by Date_„��_ Final In:pectipn by ate 7 qL <br /> Additional Comments: <br /> Applicant - Return all S copies to: <br /> P SAN JOAQ UIN COUNTY PUBLIC <br /> HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN,_P-0 BOX 2009, STOCKTON, CA 85201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE jPEM1T'NO.EH 13.24 IREV, XS- <br /> -L � <br />