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ADPL I CAT I ON,s FL]R�P ERM T <br /> .SAN JOAQUIN GOCINTY-,�ppBLIC HEALTH SERVICES � <br /> ENVIRONMTNTAL HEALTH DIVISION. <br /> �1 P-'O BOX 2009, STOCLTON, CA 95201 <br /> " (209) 468-3447 <br /> r <br /> PERVIT.EXPI <br /> y R AIR <br /> (Complete in Triplicate.) - d <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 mode 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 I -11-OG �°eVn� �' City��1SI.=7 Lot Site/Acreage <br /> Owner's Name ! t1 � � Address Phone <br /> -11 <br /> Contractor �� AddressU L'icense,No, �c� Phone 3 7 <br /> TYPE 60-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION Ll Out of-Sel'vice Well CI <br /> PUMP INSTALLATION O SYSTEM.REPAIR ❑ OTHER p Monitoring Well Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL `OTHER-WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation" _- _. Dia. of Wall Casing <br /> fi, • - <br /> U Domestic/private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications. <br /> M Public I 1 Other ❑ Delta Depth of Grout'Seal Type.of Grout <br /> GI Irfioation _ _Approx. Depth ❑ Eastern Surface Saul Installed by <br /> Repair Work Done L7 _Type of Pump H.P,. State Work loner <br /> Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter w*t <br /> Depth <br /> Filler Material & pth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/AOOITION DESTRUCTION Cl (No septic,lystem:permitled if public sewer is <br /> available within.200,ftiet,l <br /> Installation will some: Residence ZCommercial Other - � rfl <br /> Number of living units: J— Number-of bedrooms <br /> Y" <br /> Character of soil to a depth of 3 teat: Water table.depth <br /> ' <br /> SEPTIC TANK ❑ . TypelMfg Capacty - t.- _ No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation. Property.-Line• <br /> LEACHING LINE No. & Length of lines t ,. Total length/size 0 <br /> FILTER BED n Distance to nearest: Well __ Foundation a:i: Property Line <br /> SEEPAGE PITS 11 Depth Suse Number <br /> SUMPS V Distance to nearest: Well sf Foundation�� Property Line ¢ <br /> DISPOSAL PONDS ❑ - - <br /> r 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 /> Homeowner 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 /> tlon'lews of California." <br /> 5 The'applicant must call or all req 'red inspections. Complete drawing on reverse side: <br /> Signed Title: Date: <br /> t R DEPARTMENT USE ONLY t <br /> Application Accepted by DateY, Area <br /> Pit or Grout Inspection by Date Final Inspection by Date S 23 <br /> 191 <br /> 1 Additional Comments: <br /> 6 <br /> I Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 SOX 2008, STOCKTON. CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK I RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +' , Eh 13.24 IRIV,"451-5 <br />