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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNMNTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> F 1 <br /> PERMIT EXPIRES I YEAR FROM DTE 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 in 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. c <br /> Job Address ` � — City 5V4 Lot Size/Acreage <br /> r <br /> Phone <br /> Owner's Name t Addressl�l <br /> i <br /> Contractor ✓�� v Address /f" License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of service Well ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE k <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />{ 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> T of Casing_ t Specifications <br /> Gl Domestic/private ❑ Gravel Pack ❑ Tracy Typer <br /> I <br /> I"3 Public ('1 Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> l <br /> I i Irrigation —.Approx. Depth 11 Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. Stats Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> x Depth Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E I REPAIR/ADDITION DESTRUCTION 1 i INo rmitted it oublic sewer is _4 <br /> Is within 200 feet.) <br /> !Installation will serve: Residence Commercial Other /�r ^J'1o,.� OFQ FETp <br /> Number of living units: 4— Number of bedrooms -• I� �.Gf{ L4AJE FVO 5w/a"/'o Q/ti <br /> Character ofaoo to a depth of 3 fest: Water table depth " 1 <br /> ¢ . .. Capacity .. W^- o. amPartmen (� <br /> = SEPTIC TANK O . Typo/Mfg .� <br /> s "-' <br /> PKG. TREATMENT PLT.❑ � f!j Method of Disposal _ <br /> ;Distance to nearest: Well `Foundation Property tine ri <br /> 4 i 4; 1. - <br /> LEACHING LINE tit Length.of lines Total length/size <br /> FILTER SED ) <br /> 1 �" C7 Distance to dearest: Well: Foundation � 'Gr Property Line se� <br /> SEEPAGE PIT I`i Depth Size ' '" Number <br /> SUMPS _,{ C1 Distance to nearest: E 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 Isvr;, and <br /> a <br /> rules and'iegulaIkX*of the San Joaquin County - <br /> Home owncror 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 /> f empioyiny,pArson in such manner&6715bacorns.subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> F certwhich <br /> certifies the foMowinq:"I elRify thit:in�tfla_psrlormancs of the work for wthis_permit is issued, I shall employ persons subject to workman's compenss- <br /> s tion laws ofCallfornia.';,, - - r • <br /> The applicant muni call foi-all- qui specti ns. Complete drawing on reverse side. <br /> i Signed Title: Date: � 2 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date � � � Area <br /> r `.�.. <br /> Ph or Grout Inspection by Date Final Inspection by DateL <br /> 4 - ! <br /> Additional Commanu: <br /> Applicant - Return all-copies to: San Joaquin -County Public 'Health Services <br /> Environmental Health Permit/Services 1 <br /> 445 'N San Joaquin,.P 0 Box 2009, Stkn, CA 95201 r <br /> { <br /> k FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO_ <br /> k INFO <br /> Y . E413t4IR / Q .r. r <br /> i <br /> f t; <br /> : h <br />