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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 1s hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made In cositliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address A�= �,���v5 � City Lot Size/Acreage �v <br /> Owner's Name Address 3� 4r-f2wi t e �� J� Phone /�0 <br /> Contractor ✓ Address ( - itlL i <br /> � / �nse No._ S one L �0 6 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATIO�N0 SYSTEM REPAIR O �O�T,�H�ER O MO <br /> K onitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANSEWER LINES DISPOSAL FLD. lkPROP. LINE'- <br /> FOUNDATION _ AGRICULTURE WELL _e--- OTHER WELL--,e---- PITS/SUMPS J50 i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �) <br /> ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation 131, Dia. of Well Casing <br /> �omestic/Private /O Gravel Pack O Tracy Type of Casing_._�SUQee Specifications <br /> (I Public 1-1 Other n Delta Depth of Grout Seal '!92 Ty of Grout <br /> I I Irrigation r Approx. Depth I I Eastern Surface Seal Installed by�r L-eL, <br /> Repair Work Dond U Type Tof Pump H.P. State Work Done_ <br /> Well Destruction O Well D' sling Material A Depth <br /> Depth Filler Naterial A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is �(1\ <br /> available within 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. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: W Foundation Property Line <br /> LEACHING LINE O No. b Length of es Total length/size <br /> FILTER BED ❑ Distance to rest. Well Foundation Property Line <br /> SEEPAGE PITS I I Size Number <br /> SUMPS LI istance to nearest.- Well Foundation Property Line <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 /> Home owner or licensed agent'ssignature candies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person i such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cenifies the folio certify that in tie performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of Cal' n <br /> The applics Il for all required ' spec s. Complete drawing on verse side. ) Q <br /> Sp Title: � � Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3- Area 0712, <br /> Pit or t Inspection byDate, Final Inspection by ate l� <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 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> . EH 13-24IREV.i/a5) <br /> EH 14-n fJ 2 <br />