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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 -- ---- -- - <br /> (209) 468-3447 <br /> f PERMIT ESPIRES I YEAR PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I Application Is hereby msde.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> l application is trade In C=Wliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Rego t�a�o an <br /> Joaquin County Public HHeeaallt-h-Services. � <br /> Job Address _T IV/". > r � 15 -._ City Lot Size/Acreag �� <br />± '` �N--S% Addr / l � /&� _�_- Phone ��� <br /> Owner's Name _ <br /> Contractor u ' Address Yid License No." 'v✓ O Phone <br /> TYPE Of WELL/PUMP: NEW WELL V". WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well L7 <br /> DISTANCE TO NEAREST:-SEPTIC TANK - - SEWER LINEST -- DISPOSAL FLD----�-�—PROP.-L-INE� - <br /> i 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�"�l'� Dia. of Well Casing <br /> U Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications 4•-ZlI4 <br /> /MNjbiic i f.1 Other t ❑ Delta Depth of Grout Seal Type of Grout '�� ;� <br /> l ripation -rte_.-Approx. Deplh C] Eastern Surface Seal Installed by <br /> pair Work Done U Type of Pump . ' H.P. State Work Done <br /> Well Destruction O t Well Diameter Sealing Material i Depth- <br /> t Depth Piller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTAL LATION_fl_REP.AIR/Ap01-TION_7=f.1 DESTRUCTION G INo septic system permitted if public sower is f <br /> available within 200 feet.) <br /> Installation will serve: f Residence_ Commercial_ Other <br /> Number of living units. Number of bedrooms ' �$ <br /> Character of soil to a depth of 3 feet: = t !` Water table depth C <br /> SEPTIC TANK. Z O Type/Mfg Capacity `�� No. Companments <br /> PKG. TREATMENT PLT.'C1 f _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI'>. Nb. &'Length.of lines _ Total length/size l ► <br /> FILTER BED 171 Dista cn a to nearest: Well Foundation /f Properly Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well - Foundation Property Line <br /> DISPOSAL PONDS O <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 itsued, 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 perlormancs of,ttie work for ivhictflhis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." '^a - <br /> The applicant m II uir ns. Complete drawinp..on_reverr4 side.YAWSigned Title: Date: Z � <br /> R <br /> _ TMENTUSE.. ,O LY <br /> FOR DEPAR .. <br /> I <br /> Applicill.fnim Accepted by -rLa` �-"� __ Da[ad'--.�b <br /> -- Area -�-- <br /> Pit r Grow Inspection b ^ Datec-/ �� Final Inspection by"` Date <br /> Additional Comments; "b S6, 2 _ �(r er to <br /> Applicant - Return a.11 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> o- ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> INFO AMOUNT DUE AMOVNT REMITTED CASH RECEIVED By DATE PERMIT'N0. <br /> • EH 13,24 IJtEV-I/A 5) 1� ,/�r^y v'T� Jl <br /> EH^4.2e wY i ' ' 4 <br />