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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �k. 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BO% 2009, STOCKTON, CA 95201 <br /> ,q 5_jC14) g <br /> PERMIT EXPIRES I YEAR FR M DATE ISSUED <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 Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> Lot Size/Acreage <br /> ppp ,+ 127-�� <br /> Owner's Name Address 1■2 _L/ _ /hA Phone <br /> Contractor_69114Wl"J i 4ftdress Q s• ^ (/)��,,/I�� <br /> cense No �- Phone - <br /> TYPE Of WELL/PUMP: NEW WELL';9.. WELL REPLACEMENT C.] DESTRUCTION ❑ Out of Service Nell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. � PROP. LINE <br /> FOUNDATION AGRICULTURE WELL—_ OTHER WELL r� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casino <br /> Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications e R <br /> i"1 Public [I Other Fl Delta Depth of Grout Seal Type of Grout. <br /> •t*.lrrigation „( ApfxoM: Depth of-Eastern _ Surface Seal Installed by <br /> Repair Work Done D Type of Pump H.P. State Work Done <br /> Wall,Destruction ❑ Wail Diameter Sealing Material t, Depth <br /> Depth Filler Material i Depth f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION ( I DESTRUCTION [ I (No septic system permitted if public sewer is <br /> available within 200 fast.) <br /> installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth \ <br /> SEPTIC TANK. n_ Type/Mfg Capacity No. Compartment <br /> PKG.KG. TREATMENT PLT.❑ <br /> Method of Disposal OV <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Lina <br /> SEEPAGE PITS If Depth Size - Number <br /> SUMPS Ll Distance to nearest: Well <br /> Foundation Property Lina lk <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I 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 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."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 C ru;;0_111" <br /> " <br /> The app)' n t rsqu' Ins coons. Complete drawing on r rse sid <br /> Signed =FOR <br /> - - <br /> Date: <br /> ARTMENT U NLY <br /> Application Accepted byDate l re <br /> Pit Gout spaction by Date Final Inspection by Date <br /> Additional Comment: _ a <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE ?-CKAMOUNT REMITTED RECEIVED By !]ATE PERMIT'Nt]. <br /> INFO <br /> . EH 13,24t11EV.t <br /> EH 1425 <br />