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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 YEA TE 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 tittles and Regulations of San <br /> Joaquin County Public Health Services. <br /> L I < City= Lot Size/Acreage <br /> Job Address <br /> � rT— �Qf _ Phone 3 3 3 13 Kr <br /> Address "-" <br /> iQd _ <br /> Owner's Name --- � i <br /> 7 <br /> Contractor +" Address License No&� Phone <br /> WELL REPLACEMENT 0 DESTRUCTION Ll out of Service well ❑ , <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ Monitoring Well ❑ <br /> _ TALLATIONSYSTEM-REPAIR-11- ,�-- <br /> _ P_UMP.-INS -O.,- --- ----�_--=- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D15POSAL FLD. PROP. LINE <br /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑_Open_Bottom.,,�.�❑_Manteca Die. of Well Excavation Dia. of Well Casing <br /> C7 Industrial �__....,..:,�- " T ' <br /> 17.1l DomesticlPrivate (1 Gravel Pack L7 Tracy Type of Casin g- SpecificationsType of Grout <br /> I'1 Public fa Other I�1 Delta Depth of Grout Seal <br /> W-Irrivation Approx. Doth I 1 Eastern Sur Saul Installed by <br /> Done �� Z4 "") v <br /> Repair Work Done 19 .Type of Pump 1! '�-"�`� H.P. State Work �'�" I <br /> Well Destruction C) Well Diameter - <br /> * . _ Sealing Haterial i Depth <br /> Depth ?filler Material i Depth <br /> TYPE: OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION I I DESTRUCTION I i INo septic 'system permitted if public sewer is <br /> available within 200 lest-1 <br /> I <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> S Water table depth <br /> Character of soli to a depth of 3,feet: <br /> SEPTIC TANK. ❑` Type/Mfg Capacity No. Compartments _ ! <br /> `~ PKG:"TREATMENT PLT:O - 'T� T .. T^ Methcyd of Disposal <br /> R <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE ❑ No. a Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line. <br /> a <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> F , <br /> I 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 r <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 shat1 not <br /> workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any parson in such manner as to become subject to <br />' certifies the following: -I certify that in the performance of the work for which this permit is issued,k shall employ parsons subject to wo►Iiman's compenaa <br /> tion laws of California." <br /> The applicant at II for all required Inspections. Complete drawing on reverse side. ti <br /> Signed tie: ��_. <br /> Data: 1r2 <br /> ' F R D SE ONLY <br /> Application Accepted by <br /> Data ©�' - Area � <br /> d � — <br /> t <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> San Joaquin County Public Health Services <br /> Applicant - Return all copies to: <br /> Environmental Health Permit/Services ? <br /> ! 445 K San Joaquin, P O Bos 2009, Stkn, CA 95201 <br /> IFEE <br /> NFO AMOUNT DIE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> z . Eri 1]-21 TREY. <br /> EH 14.26 <br />