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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 1EAR FROM DAIE ISSUM <br /> (Complete in 'Triplicate) <br /> i <br /> Application is hereby;aade,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 1662 and the Rules and Regulations of San <br /> t Joaquin County Public Health services. <br /> Job Address ^FCity Lot Size/Acreage <br /> � 1 Jylddress <br /> Owner's Name y <br /> �� Jr ��-_ � Phone <br /> Contractor 5' ddress .�- 8 License No. 4_956-Phone ��� <br /> t TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT f7 DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION..❑ SYSTEM REPAIR ClOTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. ' PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL } PITS/SUMPS L y� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing i <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public n Other 11 Delta Depth of Grout Seal �L Type of Grout <br /> I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. tate Work Done <br /> I' Well Destruction X Well Diameter Sealing Material i Depth <br /> f w.µ <br /> Depth Filler Material 4 Depth v�� <br /> s.TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feel.} <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms q <br /> Character of sod to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments, <br /> PKG. TREATMENT PLT.❑ Method of Disposal 1 <br /> R Distance to nearest: Well 4 Foundation Property Line { <br /> ` LEACHING LINE 0 No. & Length of lines Total length/size <br /> C FILTER BED ❑ Distance to nearest: /Well �-_Fo dation Property Llne _ <br /> SEEPAGE PITS I I Depth Site Number <br /> SUMPS Ll Distance to nearest., Well T. Foundation Property line <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 T <br /> rules-wid regulations of the San Joaquin Cou <br /> msnty - .- <br /> f Hoowner or licensed agent's signature certifies the followings 11, certify that iri the perfo►msnce 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 /> # certified the following: "I certify that in the performance of the work for whic_h;this-permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califoima." <br /> The applicant mu �tl uir tions. Complete drawing on re crap side: 9 <br /> i <br /> s SignedTitle: Date: <br /> FORDEPARTMENT USE ONLY 7, <br /> Application Accepted by '2{ Date L4_1 Area <br /> c� <br /> Pit or Gout Inspection by Date Final Inspection by Date�x 2 <br /> I - -Additions! Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Env ironmental�Realth'per[FIt/Services- "I r <br /> 4.45, N:�Sa. Joaquin;'P O'-Box,2009, Stkn; CA 95201 <br /> 4 FEE AMOUNT DUE AMOUNT-REMITTED CK RECEIVEo BY DATE PERMIT'NO. <br /> INFO CASH <br /> .-EH 13-24t11EV.tixei WO <br /> EH 1448 yP '' <br />