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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_ YEAR FROM DATE ISSUE <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 coeWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ` <br /> Joaquin County Public Health Services. 1 / <br /> Lot Size/Acreage <br /> Job Address Q t$,, = r!` Cit Q <br /> rA�fY Address' Phone <br /> Owner's Name _ ., <br /> Contractor 1 � ��ddress � � �`tZ ��� License~No. C6� _Phor � <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well I;1 <br /> PUMP INSTALLATION SYSTEM REPAIR d OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �Vndustriai ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— Specifications <br /> I'1 Public Cl Other n Della Depth of Grout Seal Type of Groul <br /> I I Irrigat <br /> i <br /> o <br /> n <br /> [���� ^Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done C4oLlType of Pump V0 4} H.P. `t- d State Work Done <br /> Well Destruction ❑ Well Diameter Well Material i Depth <br /> Depth �DO f hiller Material i Depth <br /> TYPE OF SEPTIC'WORK: NEW INSTALLATION-1 1 REPAIR/ADDITION-1-1—DESTRUCTION l 1 (No septic system'permitted.it public sewer is <br /> available within 200 feet.f <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms Y ? <br /> r <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 Oisposal A <br /> Distance to nearest: Well Foundation Property Line yr , <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size !` <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> f <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS. Ll Distance to nearest: Well Foundation 'Prdperty line <br /> DISPOSAL PONDS ❑ <br /> t <br /> 1 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 _ r <br /> rules and regulations of the San Joaquin County l <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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion Iww of California." <br /> The applica ntl► u0 frr:equirinspsjctions. Complete drawing on reverse side. j <br /> Signed Xc.—/y �. - Title: 414 Date: Z i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by &&� Date s res ` <br /> Pit or Grout Inspection by Date Final Inspection b Date <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 AMOUNT DUE a AMOUNT REMITTED ASH RECEIVED BY DATE PERMi7'NO. <br /> INFO (L <br /> . EM1143-24-MInEV.,,Mbe � Ca vo �r3 �3^ o g 5 <br /> EN li•7a <br />