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APDL ATI-ON FOR PERI[I T <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 1 YEAR FROM DATESI SUED <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. tiC�� I1� <br /> JobAddress 11 t Size/Acreage <br /> q0, sNattV 6 i s , ne_ <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out,of Service Well ❑ <br /> PUMP INSTALLATION-❑ SYSTEM REPAIROTHER ❑ jMonitoring well C1 <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 I dustrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Wel!Casing <br /> stic/Private ❑ Gravel Pack 11Tracy Type of Casing_ Specifications <br /> I'I Public C1 Other Fl Delta Depth of Grout Seal Type of Grout I{ <br /> I I Irrigation —Approx. Depth l I tern Surface Seal Installed by ] <br /> Repair Work Done 0 Type of Pump H.P. State Work Done I <br /> We" Destruction ❑ Well Diameter Sealing Material i Depth. <br /> Depth filler Material i Depth tu <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 13 DESTRUCTION l I (No septic system permitted-if public sewer is <br /> t _ ,.__.,_._availabie.within 200 feet.) <br /> Installation will serve: Residence e Commercial_ Other <br /> Number of living units: Number of bedrooms I <br /> Character of sob to a depth of 3 feet: f Water.table depth t <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments / <br /> PKG. TREATMENT PLT.❑ l�••y.•.�u,a _. Method of Disposal I <br /> Distance to nearest: Well ; Foundation Property Line <br /> LEACHING LINE Q No. S Length of lines Total length/size <br /> FILTER SED 0 Distance to nearest. Well Foundation Property Line <br /> � t <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS. Ll Distance to nearest: Well y Founds ion Pr I <br /> operty Line <br /> DISPOSAL PONDS O ,. i I <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 SariJoaquin. .County <br /> Home owner or licensed agent's eignmuire canifies 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 taws of California." Contractor's hiring or sub-contracting signature <br /> cenifies the following:"I cert' at in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion Iowa of Calif nls." , <br /> The applies call for an pectic s. Complete draw• Jon , e s' <br /> 26�1Sig T' Date: <br /> FOI&DEPARTMENT USE ONLY <br /> o <br /> Application Accepted by a&o,..a L Da s -- '— Area <br /> Pit or Grout Inspection by Date Final Inspection by )It Date 0 f Z <br /> Additional Comments: <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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMWNO. <br /> . EH1324IREV.1i*5! 1x <br /> EH 14•2e ��dD �v ' I S 0L <br /> 1 l �l <br />