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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 ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in coeipliance'vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> a I <br /> Job Address _ i©o g ��'�5d City L�rbXi9(2 Lot Size/Acreage <br /> r Owner's Name B T CO 6-)-6 /� Address i Phone <br /> Contractor O x SO/° Address 660A 9(-f1w U ) License No. �yy E'9� _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [1 DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL,.a T OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ci Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I1 Public Ia Other fl Delta Depth of Grout Seal Type of Grout <br /> € I Irrigation —.Approx. Depth I I'Eastern--_�-— Surface Seal Installed by <br /> Repair Work Done"_U Type of Pump ' H.P. State Work Done_ <br /> Welf Destruction 07 Wall Diameter Sealing Material•i Depth <br /> Depth Filler Material's Depth t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I i INo septic system permitted if public sewer is <br /> ■ available within 200 feet.) <br /> < Installation will serve:, Residence_`� Commercial____ Other C- # <br /> Number of living units: .,.,.,- Number of bedrooms <br /> Character of soll to a depth of 3 feet: Water table depth <br /> c SEPTIC TANK: a` Type/Mfg _Capacity o a r._.No..Compartments <br /> I PKC. TREATMENT PLT.© Aljd �VZ7,& <br /> Method of Disposal <br /> ' 11 <br /> Distance to nearest: Well n - Property Line <br /> LEACHING LINE C1 No. 8 Length of lines r � Total length/sire <br /> FILTER BED M Distance to nearest: Well oVdatlon 1�� Property Line ------ <br /> SEEPAGE <br /> - -SEEPAGE PITS t I I Depth - t "` Sire_ 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 /> Homs owner or licensed agent's signature certifies the following: 1 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•tontracting 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 componss- <br /> tion laws of CNiforrtks." <br /> # The applicant mus call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> F DEP TMENT SE ONLY <br /> f <br /> Application Accepted by Date Area <br /> t <br /> Ph or Grout Inspection by Date. Final Inspection by Dats <br /> r <br /> Additional Comments: <br /> 4 l Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. <br /> INFO rA f A.-H <br /> I . 01}2 I11EV.rirsi / r1t7 <br /> 4ZIZ <br /> �.O aF � f✓ ©-'/ <br /> Eft4•20 <br /> 1 <br />