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ii <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 /> 2ERMIT 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 compliance1vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health 8 rvices. <br /> Job Address '� City Lot Size/Acreage <br /> toil A 614 <br /> Owner's 50,1e Ll 14 Address a I Phone <br /> Contrac • 6—OUkddres! �• s License 1V Phon <br /> TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT �} DESTRUCTION ❑ Out of Service Well ❑ <br /> {" PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Nfonitoring,well <br /> DISTANCE TO`NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> '. : FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS,_ <br /> INTENDED USE` TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial � ���.�❑ Open Bottom❑ Manteca Dia, of Well Excavation Dia. of Well Casing-- <br /> U Domestic/Private^F=.y.-❑ Wave] Pack O Tra.cy., �. •Type of Casing Specifications <br /> - <br /> M Publics iia Others � ❑ Delta °�;� Depth of Grout Seal Type of Grout F y { <br /> CI lrngaijon, j _ ApproDepth ❑ Eastern Surface Seal Installed by a <br /> Repair Work Done E3 1Type of Pump, H.P`�� State Work Done_ <br /> Well Destruction i ❑- Well Diameter SealingtiMateiial i Depth <br /> ki �� F t Depth „ <�^ ` Piller Material:& Depth <br /> TYPE OF SEPTIC WORK: NEW"INSTAELATION 0 REPAIR/ADDITION M DESTRUCTION o septic system permitted if public sewer is <br /> available within 200 feet,) <br /> Installation will servir-*�Residence 5`•Commercial_cher l"\) <br /> Number of IivinQ units: _" Number of,"be o s <br /> Character of *oil to a depth of 3 feet: Water table depth <br /> SEPTICrTANK\ t ❑ Type/Mfg Capacity �No\Compartmants <br /> PKG. TREATMENT PLT, Ll � Method of Disposal <br /> Distance to nesre tv: , Ve11 Foundation Property Line <br /> i <br /> LEACHING LINE f Cl No. & Length of lines la Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth f Size Number <br /> SUMPS �,,.``.EI""`Diitance o._e-to nearest:re ._ <br /> Well <br /> DISPOSAL PONDS ❑ - N <br /> I hereby certify that I have prepared this application and that.the„woek_will be done iri.accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin','CountyT ! i k <br /> Home. or lice agent's signature.certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall of <br /> employ any person i s h manner as to become subject to workman's compensation laws of,California," Contractor's hiring of sub-contracting signatu <br /> certifies the followi certify that in th pe rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws Calif <br /> The sp. at for all requ' Inspections. om I wing a�e side. <br /> M <br /> Signs � Title: T _ Date: <br /> FOR DEPARTMENT USE ONLY i <br /> Application Accepted by Date �` Q Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 7 <br /> Additional Comments; <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> } ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 495 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 65201 <br /> INFO ff <br /> AM Dt1E ;� AMOUNT REMITTED CASH RECEIVED BY OATE PERMIT'NO. <br /> + EH 13.24 1REVV, i n S! �; (✓ n y�/�7Q�� <br /> EH <br /> il <br />