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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSPED <br /> (Complete in Triplicate) <br /> Application is hereby Ito San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in edl`jlianee 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 d S_ `'is R , 0.� __ City Lot Size/Acreage / Q : <br /> Owner's Name AddressPC) �1��- 5 70 e Phone <br /> F Contractor n Address _-0 .rz L4c ;L (��License N ��3 Phon —a-77 <br /> TYP_E_O.F WELL/.P_UMP---_,- ANEW WELL,O-.,r.-..�„WELL_REP_LACEMENT.Ri QESTRUCTIONof Service Neu ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> * Industrial I❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C1 Domestic/Private El Gravel Pack ❑ Tracy Type of Casing— Specifications <br /> I'I Public 1"1 'Iother Cl Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation Approx. Depth I I Eastern—Surface Seai Installed by <br /> Repair Work Done U Type of Pump �� H.P. tate Wor one <br /> G Well Destruction Well', Diame erlSealing Material L Depth v rA At OXA L) <br /> Depth biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 lNo septic system permitted if publi r i <br /> 1 '1I`1 r, available within 200 feet.) � r <br /> t Installation will serve: Residence_ Commercial_ Other p <br /> Number of living units: 11f Number of bedrooms <br /> Character of sell to a depth of 3 feet: Water table depth <br /> �. SEPTIC TANK. ❑ Type/ Mfg Capacity No. Compartments <br /> f <br /> PK G. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation 3� y Property Line <br /> LEACHING LINE C, No. 8 Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth^ Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I� <br /> I hereby certify that 1 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 Saiz Joaquin County <br /> Home owner or licensed agent''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: '9 card.,that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." �I <br /> The spplican must call r all roquired ' spections. Complete drawing on reverse side, <br /> 4 .�e 5 c' <br /> Sig� - Title: Date: <br /> ± I R DEP TMENT USE ONLY <br /> App4cation Accepted by Date Area <br /> Ph tion by to Final Inspection by Data S(L' <br /> Additions Lnts: <br /> Applicant - Return all copies to: San Joaquin County Public`Healtb Services <br /> Environmental—Heai-th7Permit7'8ervicesY <br /> i 445 .N San-Joaquin, P O 80x;2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT.DUE AMOUNT REMITTED CASH RECEIVED'SY PATE PERNIMN0. <br /> • EH 1341 IAEv,rrn61 <br /> I EN 11.211 rr//yy�PI 6 /a �/ / <br />