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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 I YEAR F&QM DATE ISSUBP <br /> (Complete in Triplicate) <br /> Application is hereby made`ito San Joaquin County for a permit to construct and/or install the work herein described. This <br /> 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 Heal i Services. <br /> Job Address <br /> 1 `. �"C�'1�1�.� VIA City '� Lot Size/Acreage <br /> Address 1�Z.. Phone <br /> Owner's Name `y <br /> Contractor ` T Address ,\ License No Phone ` <br /> Service Well L-I <br /> TYPE OF WELL/PUMP: i� NEW WELL ❑ WELL REPLACEMENT DESTRUCTION L1 Out Mona ring Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> �F. .. <br /> `- INTENDED USE"" '"TYPE OF WELL- PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications i f Well Casing A <br /> Gr!" T of Casin Specifications �\ <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type g- <br /> f'1 Public Cl Other <br /> n Delta Depth of Grout Seal Type of Grout_ <br />' nigatian _�A pprox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done IJ Typei�of Pump H.P. State Work Donee <br /> We" Destruction D Well`Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 -REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> II available within 200 feet.I <br /> Installation will serve:y Resider ce— Commercial'.Other" r 'r <br /> �M Number of bedroom$ .7 /' . <br /> I Number of living units: <br /> f Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIG TANK r' © Type/Mfg Capacity No. Compartments <br /> ' <br /> PKG. TREATMENT PLT.-0 ��` _ - -" "`- " " `- ` -. - - Method of Disposal <br /> . . <br /> Distance-to nearest: Well.L Foundation a Property line <br /> LEACHING LINE '❑ 'No.-,--Length'of-lines "` ` '" - Total length76ize <br /> FILTER BED C7 Distance to nearest: Well Foundation Property Line .•., r <br /> SEEPAGE PITS I I Depth Size Number f <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ��N _ -. ' . <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordi`nant�s;•statilaws, and <br /> i rules and regulations of the San Joaquin County �' <br /> Home owner or licensed agent$'signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I$hill•riot- <br /> employ any person in such mani <br />