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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 20091 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 /> I 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. f <br /> Job-Address �r Z Zl �Z* dAft _91 '2C --- — - City Got Size/Acreage <br /> Owner's Name ��L Address 7 C "L r r"Phone <br /> �vX � • ���,�ru� � <br /> Contract or _ Address License No. —'Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS Al_ FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS <br /> INTENDED USE TYP ELL PROBLEM AREA CONST ION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom !� Manteca of Well Excavation Dia. of Well Casing t�! <br />+ Cl Domestic/Private ❑ Gravel Pack n Type of Casing_ Specifications <br /> f"i Public t !� Other n a Depth of Grout Seal Type of Grout N <br /> I I Irrigation _Approx. De I I Eastern a Seal Installed by eel <br /> Repair Work Done U Type o! p H.P. State Work Dana_ <br /> Well Destruction ❑ Well Diameter Sealing Material i <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> - 4 available within 200 feet.) <br /> I Installation will serve: Residence_ Commercial ____ Other 3 76 l o F r�q r ` �� G <br /> Number of living units: Number of bedrooms X&/9L,feZ/ �✓� "g4? L`Ll yQ � t <br /> Character of sod to a depth of 3 feet: Water table depth <br /> SEPTIC TANK: ❑ Type/Mfg Capacity No. Compartments <br /> I <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest- Well Foundation Property Line Z <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> r SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well 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 <br /> rules and regulations of the San Joaquin County <br /> Home owner 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 /> sonifies the following: 1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's eompenss- <br /> tion laws of California." <br /> The applicant ust for ail req tions. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY _ + <br /> Application Accepted by Datel� res <br /> 4 <br /> Ph or Grout Inspection by Date i Final In Oat✓J <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 H San Joaquin, P 0 Box 2009, Stkn, CA 95201 - <br /> FEE AMOUNT DUES AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO.. <br /> INFO ` f ASM <br /> NI <br /> . 614 13-26(REV.f/ti S 1�� / �• r I'l � /p� 2fC�Q <br /> EH 13-24(R { V <br /> _ <br />