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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH 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 f <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 Safi Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Publi�cj�Health Services. <br /> � y� <br /> Job Address / v� t'3 �� fl City Got Size/Acreage <br /> Owner's NameT -��` 2``N ` �� Address Y '- --- t �1��1!i ._' .Phorie <br /> Conttactor Addressi d� p License N9 Phone <br /> ;TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DE$TAUCT1ON 0 Out of Service well ❑ <br /> i PUMP INSTALLATION 0 SYSTEM REPAIR 0 ,Tt OTHER'❑ Monitoring Well C] <br /> `DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> y FOUNDATION AGRICULTURE WELL OTHER WELL L Pl_TS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' s ; <br /> r171 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t A <br /> 'D Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ ' ' Specilications <br /> il'1 Public 173 Other F1 Delta Depth of Grout Seal Type of Grout <br /> it I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by 1 ` <br /> H <br /> Repair Work Done U Type of Pump H.P. Stats Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material i Depth <br /> r <br /> Depth 1!illgr,_lYsteria1,&..Deptb_ ._.• -- ` Q <br /> ,TYPE OF SEPTIC WORK:, NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I 1 lNo septic sysienl permitted iVpublic sewer is <br /> i availablaUithif 200 foot.I <br /> t Installation will serve: Residence 1� Corrimarcial.. Other r r <br /> Number of living units: L_ Number of bedrooms <br /> i Character of soil to a depth of 3 feet: Water'tableMepth <br /> 'SEPTIC TANK. O• Type/Mfg T Capacityompartments <br /> ♦PKG. TREATMENT PLT.CI'Ye �►'T j,rMethod"61[i.Disposal " <br /> Dis snce-to nearest:, Well 'A/40 Foundation Property Lin,,', <br /> BEACHING LINE LP--No. & Length of lines- '= Total length/size , i <br /> FILTER BED 0 Distance to nearest. l Well�``-'�r-�- Foundation 19 /­_'_r ^Propsrty Line '!p <br /> I <br /> EEPAGE PITS bd Depth r_ Size ! � Number <br /> "SUMPS LI Distance to nearest: ' Well Foundation 4 <br /> K _ : /73� m'7_ Property Lins <br /> :DISPOSAL PONDS 0 r <br /> I hereby certify that I have prepared this applicalion'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 r <br /> Home owner or licensed agent's signature certifies tpe following: "I certify that in the performance of thework for which this permit is issued, 1 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 /> cfftifia.the.}4Mowin9: ^I,certify,thttt in the p�Aormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion Iowa of Cajifornla.'ti <br /> The applicant must call f NI requ'ed inspections. Complete drawing on reverse side. <br /> a <br /> $i nod <br /> g Title: Date: <br /> I, FOR DEPARTMENT USE ONLY ' <br /> Application Accepted by a 4 94 1 IK _ Date Z.7 �1� Area 2 41 <br /> � <br /> l t <br /> Pit or Grout Inspection by Date Final Inepectian by ' Data <br /> Additional ComrMnb: <br /> r.. h . . .; <br /> Applicant Return all copies to: San Joaquin County Public Health Sevices <br /> -- T 'EnviroWfieiital Heal_th-PerisWServirces S <br /> * !Y 445 N Sad Joaquin, P O Box 2009, Stkn, CA 85201 <br /> IFEE <br /> AMOUNT DUE AMOUNT REMITTED CK ECEIVk BY p TE PERMIT'NO. <br /> s EM 132 (REV.rIx51 N V, <br /> EH 14-A t <br /> l <br />