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APPLICATIONFORPERMIT 1 <br /> SAN JOAQUIN COUNTY-PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCSTON, CA 95201 <br /> (209) 468-3447 <br /> R PROM DATE 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 /> t 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 Service.-s..� <br /> Job Address 3 / eVS�,a�-' v1�% City�1 . Lot Site/Acreage <br /> Owner's Name Address _.._ _______ Phone 9 <br /> Contractor Address,01410*fid> License N727Vr Pha <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTIOR>Q Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO., PROP. LINE _" <br /> r <br /> FOUNDATION AGRICULTURE WELL -OTHER WELL, L PITS/SUMPS <br /> INTENDED USE­-TYPE-OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS.- <br /> fl <br /> PECIFICATIONS.Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Cas <br /> iA <br /> Komestie/Private X Gravel Pack ❑ Tracy . Type of Casing ��rCi Specifications <br /> M Public f-� Other p DriIts 'k '�,, Depth of Grout Seal ._/V Type of Grout-�� <br /> CJ Irrigation 'L3 Approx. Depth 4'1 Eastern Surfac Saul Installed by - <br /> I Repair Work Done U Type of Pump H. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 ,REPAIR/ADOiT10N 0 DESTRUCTION G (No septic system permitted if public sewer is Q <br /> available within 200 feet.) <br /> t Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - - •Water table depths <br /> SEPTIC TANK: ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. O Method of Disposal , r <br /> Distance to nearest: Well Foundation ,Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED t_I Distance to nearest: Well Foundation f -PrapanV Line <br /> , i f <br /> F � <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: ' Well Foundation Property Line <br /> DISPOSAL PONDS ❑ e <br /> IA"I I hereby certify that I have prepared this application and that the work will be doni in accordance with San Joaquin county ordinances, state laws, and \'"" <br /> ' rules and regulations of the Sen Joaquin County J <br /> Home owner or licensed agent's signature certifies the following: "I candy 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 persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must for all rep 'red inspection6. Complete drawing onrreverse.sidd. .. <br /> G• <br /> Signed Title: ` Date: 5t:21 <br /> 1 <br /> A PARTMENT USE ONLY 5 <br /> ApCio <br /> n cceptad by Date r Area <br /> k � <br /> 7 Pitou nsgection by Date �U Final Inspection byiM Date <br /> Additional Comments: 2r <br /> VW <br /> Applicant - Return all copies to: SAN JOAQUIN co TY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT TED DUE AMOUNT REMITCASH RECEIVED BY DATE PERMIT'NO. <br /> a EMt]141REV r qSr $ <br /> �y r� �rD� loftA-4 �3V % V �� <br /> EH i{•30 l P <br />