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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR FROM DAIE 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 Rules and Regulations of San <br /> Joaquin County Public Health Services. ,may <br /> Job Address ✓ -_ _ ___�/r�1 �/!Q City ,•CJZJ Lot Size/Acreage <br /> Owner's Name _Ll10C-<11 2 Y.r!_& ddress ; OE Phone 7� <br /> Contractor DD. 1 /VS GCS- Address /0' <br /> 1 License Na. a/ _ Phone <br /> TYPE OF WELL/PUMP: NEW WELL_4 WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service well ❑ <br /> PUMP INSTALLATION'' SYSTEM REPAIR ❑ OTHER ❑ Monitoring well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ so SEWER LINES DISPOSAL FLD, PROP. LINE �U <br /> FOUNDATION AGRICULTURE WELL -" OTHER WELL G PITS/SUMPS <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑Open Bottom ❑ Manteca Dia, of Well Excavation ZZ Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing A� 1(Specifications 9:Z4 Z90 <br /> R Public --�l'-{1 Other ❑ Delta Depth of Grout Seal Type of Grout—&&L/ t } <br /> CI Irrigation C;Za Approx. Depth 0 Eastern Surface Seal Installed 1p 4 V" <br /> Repair Work Done U Type of Pump H.P, State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material A Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal (� <br /> Distance to nearest: Well Foundation Property Line` <br /> LEACHING LINE ❑ No. IS Length of lines Total' length/size <br /> FILTER BED Ll Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby comity 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 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 laws of California." <br /> The applicant requir. ions. Complete drawing on reverse—side. <br /> Signed knz—.Tide: � �� '"^ Data: <br /> FO D ARTMENT USE ONKY <br /> Application Accepted by Date -31 3 Area <br /> Pit or Grout Inspection by Date Final Inspection by �~ Data !J — <i <br /> Additional Comments: <br /> Applicant - Return all copies to., SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> Ek 13-24 OtEV.i/NES OU 1"N�3 <br /> EN�r.M ` I-oy< <br />