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r <br /> 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 /> I <br /> • PEMIT EMIRES 1 YEAR ROlit DATR T.SS'Tvn <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 ccupliancelvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _ � "t'YYlrttZ Olr� . City Lf Lot Size/Acreage <br /> Owner's Name r J �� �Y I°`�V = Address Phone <br /> Contractor T rr ru d e�� AddT' prn -niU kv Q S'2D� License No.- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <br /> WELL REPLACEMENT LIDESTRUC7ION Cl <br /> Out of Service well Cl <br /> PUMP INSTALLATION,, SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> isrDOmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> .M-Public C] Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation _"__Approx. De th 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> 1 Sealing Material i Depth <br /> Depth 1777 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION 0 DESTRUCTION 0 fNo 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 <br /> Character of soit to a depth of 3 feet: Water table depth <br /> SEPTIC TANK: (3 Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size 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 /> 11 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 subjact.to workman's compentia• <br /> tion Iowa of California." <br /> The applicant mall for all requir ins tion Complete drawing on reverse ida. p <br /> Signed Title: _-- Date 2-'7`J ....._ <br /> FOR EPARTIMENT USE ONLY <br /> Application Accepted by rQdA9% _ Date Area <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> t Additional Comments: -- <br /> Applicant - Retum all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N.SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUI_ AMOUNT REMITTED CKRECEIVED BY DATE PERMIT N0. <br /> INFO CASH <br /> ♦ EH 13"2t IItEV.1/015; ,n� -- L 2 �q c� Cl a �3 - <br /> KH 114,26t <br /> r <br />