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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 1 YEAR FROM 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 Ilervices. <br /> Job Address City <br /> _� Lot Size/Acreage <br /> �� rTr, r4 <br /> Owner's Name <br /> '; Address X7 _�h `���r - Phone <br /> Contractor <br /> 1 Address License No. Phone 6 <br /> TYPE OF WELL/PUMP: : N WELL ❑ WELL REPLACEMENT .. DESTRUCTION Ll Out of Service Well <br /> ' PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR OTHER ❑ Monitoring 41611 E] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' of Casing- <br /> 1-1 <br /> Specifications <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type g- <br /> ['1 Public I"1 Other 1-1 Delta Depth of Grout Seal Type o1 Grout <br /> I I Irl'IU ation _Approx. Depth I I Eastern Surface Seal installed by <br /> ��� <br />! Repair Work Done U ' Type of Pump �+ <br /> /�/ ld[�� H.P. 1 Z State Work Done <br />{r We"Destruction ❑ Weil Diameter fit �- Sealing Material Depth <br /> Depth r Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIRIADDITION I I DESTRUCTION I I lNo septic system Pe►mined i} public sewer is <br /> available within 200 feet) <br /> installation will serve: Residence Commercial— Other j r' <br /> Number of living units: Number of bedrooms ` w <br /> tl � <br /> Character of I101i to a depth of 3 feet: a r Water t�bep"{�jv <br /> SEPTIC TANK ^F 0 Type/Mfg Capacity I No, Comp�t�rne It ED <br /> hm,'�.tl:i <br /> PKG. TREATMENT;PLT.❑ Method of Di <br /> I <br /> Distance to nearest: Well j soo <br /> Foundation Propany line E P v <br /> LEACHING LINE Cl : 6'i'Lekth of,Iinei ! Total length/si& BLIC HEALT+�I SERVICES <br /> - 4NQJ�,MEN1AL HEALTH €3iVIS <br /> Pro ION <br /> # FILTER BED a 171---Dia a6ca fornearest: ":Well ! Foundation <br /> _...,.,..cam. <br /> f .I ,..r Number <br /> SEEPAGE PITS III Depth Size <br /> SUMPS " . L1 Distance to nearest: Well -,Foundaaon Property Line <br /> DISPOSAL PONDS_.- ❑ _ <br /> I hereby certify that,t have prepared this applica�ion ind thatihe work will be Gone in accordance with San Joaquin county ordinances, stela laws, and <br /> rules and regulations,ol the San Joaquin County <br /> Homa owner or licensed agetli's signatuis�arlifie�the toll ing: Icer rfy Thai iri the per16rinnance of the work for which hi permit is issued, i shall not <br /> employ any perao ' uch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub•coAtracting signature <br /> f certifies t :'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to y0orkman's compensa. <br /> k <br /> —certifies <br /> -Cala <br /> I The applican t all for alt t.Linspecii Complete drawing on rave side.A� <br /> signed Title: i Date;_ <br /> d� <br /> FOR DEPARTME USE ONLY 1 { <br /> Application Accepted by <br /> Date <br /> L L Area Z <br /> Pit or Grout Inspection by# Date Final Inspection by Oats �G U <br /> �s <br /> Additional Comments: <br /> Applicantl' - Return all copies to. San Joaquin County Public Health Services <br /> I <br /> Environmental Health Permit/Services <br /> 4 445 N San Joaquin, P O Box 2009, Stka, CA 95201 <br /> 4 <br /> FI FEE <br /> r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> a EM 13.24 I11EV.i/A51 <br /> EN 14.16 <br />