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t <br /> .� APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HTALTH 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 compliance with San Joaquin County Ordinance No. 549 and 1$52 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.�/� JA&(� <br /> V <br /> yj (� <br /> ob Address v- 0��x����( 1 City Lo Size/Acreage 15'ttc <br /> [� �`�Z <br /> Owner's Name }1 �'- �1� �,�'QVL Address J-1 L V LTJ J_11J Phone <br /> Contractor . Address License Na. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Yell ❑ <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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -- Dia. of Well Casing <br /> fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public EI Other f-! Delta Depth of Grout Seal Type of Grout <br /> I 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 /> Well Destruction O Well Diameter Sealing Material A Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it 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 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of tines Totat length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Lina <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 /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies the following; "I certify that in the performance of the work for which this permit is issued, I shell not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 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 a alifornia." <br /> / The apps* n mustcal or ad in coons. Complete drawing on reverse side. <br /> 1J15�^� Title: Date: <br /> Y � <br /> �� R DEPARTMENT USE ONLY <br /> Application Accepted by . bra � 1 , ...__.._,— Date 3' Area 1-4 <br /> Pit or Grout Inspection DY Date Final Inspection by Data Z <br /> Additional Comments: <br /> 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 95201 <br /> FEE 4NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. <br /> ♦ EH 15.24)stew.1/e 5! ,�� � / U _�,` /� �322� <br />