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APPLICATION FOR PERM I T <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 <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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Z 0 , AGA�u City <. S Lot Size/Acreage 1L A C <br /> Owner's Name Skop Address SA/ndr Phone -6 u L <br /> Contractor(S al-61 a(ZO Address l-a 6ey op License No. 77 'S Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DEST UCTION O Out of Service Well O <br /> PUMP INSTALLATION SYSTEM REPAIR O OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. L <br /> PROP. LINE a'si <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / <br /> O Industrial O Open Bottom O Manteca Dia. of Well Excavation / Dia. of Well Casing b <br /> >W Domestic/Private Gravel Pack O Tracy Type of Casing_. oyt Specifications w-Y� <br /> I') Public fl other (l Delta Depth of Grout Seal S O Type of Grout C*,^ 4 <br /> I I Irrigation 4142-Approx. Depth I I Eastern Surface Seal Installed by _CBI- 70SAL)%I. <br /> Repair Work Done U Type of Pump S_V-d H.P. `t State Work Done 0w- STa14v <br /> Well Destruction O Well Diameter Sealing Material • Depth <br /> Depth Filler Material i Depth �. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. b Length of lines Total length/size b <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS O <br /> 1 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 /> Homs 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 subcontracting signature <br /> certifies the following: "I 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 of California." <br /> The applicant must call or all required inspections. Complete drawing on reverse side. <br /> Signed X `ez" 40 t041� Title: OW/V 6Q Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �b 4� Area <br /> Pit o Gr Inspection b Date _� Final Inspection by <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 /> IFFY AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. <br /> N <br /> 00 <br /> . EN1420 /3-2/(REV.1in5) n p S' a <br /> EH 1 N !/ <br />