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APPLICATION FOR PERMIT '-a -,. , , ;,,a <br /> s .. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ,_ Ky <br /> ENVIRONMENTAL HEALTH DIVISION S ' <br /> P O BOX 2009, STOCKTON, CA 95201 MAR 1 2 1A <br /> (209) 468-3447 �'lVNIV1 ,. <br /> `FTA L ,H aA TH <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application to made in compliance with San Joaquin County Ordinance.No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public HealP Services. ► <br /> Job Address Z ,P& ` C Lot Size/Acreage <br /> ,4�100 <br /> 0 ner's No Address Phone <br /> C n c r tcense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEME T n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> lNTENDEO L <br /> USE TYPE OF WELL AREA CONSTRUCTION SPECIFICATIONS,f <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> -Qomastic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications I <br /> Q Public C1 Other s O Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation Approx. Depth e��astern Surface Seul_Installed by <br /> Repair Work Done U Type of PumhidL Z. <br /> �LH.P. - --- _ S6(" <br /> ' e ork D no _ <br /> Well Destruction ❑ Welt Diamete Sealing l/aterial.i Depth <br /> Depth Filler (Material & Depth F ' <br /> TYPE OF SEPTIC WORK-NEW INSTALLATION 0 REPAI141ADOITION M DESTRUCTION CI INo septic system permitted if Wobtic sewer is <br /> availabi?within 200 loot.1 �+ <br /> Installation will serve: 'Reaidance— Commercial— Other_ -- <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feat:it - — Water table depth <br /> SEPTIC TANK: Type/Mfg'f -Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ `$ "� Method of Disposal r <br /> Distance,to'nea rest, Well Foundation Property Line <br /> LEACHING LINE C1 r No...B Length of lines Total length/size <br /> FILTER BED n` Distance to nearest: Well E-Foundation Property Line <br /> _ r-a -------.--- <br /> SEEPAGE PITS i l' bepth Size j Number <br /> SUMPS "Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS o <br /> I hereby certify that I have prepared this application and that the work will be done in'accordancs with San Joaquin county ordinances, state ellaws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent'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 person in such manner as to become subject to workman's compensation laws of California." Contractors 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 Iowa of California." f 1 11 <br /> The applic n ust coil foir all required inspections. Complete drawing on rev rse side <br /> Sign ff_�+`/1-69d TitlA/ <br /> / Date: �1 <br /> FR D RTMENT USE ONL <br /> Ap thSrt711;Ee 1�2Tby - ----ust_e ", ]l � Area C?, 1 <br /> ti, D2� ZS <br /> Pit or Grout Inspection by Date Final Inspection_by te' <br /> I <br /> Additional Comments. — <br /> 3 <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE ' AMOUNT REMIT'TEO CK RECHVEO BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH13.24MEV. Hsi <br /> EH.4-ie <br />