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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 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 1862 and the Rules and Regulations of San <br /> Joaquin Count <br /> y Public Health Services. / _y <br /> Job Address ld !®0 �Q�C�IL rG.�, rw City Lot Size/Acreage <br /> v <br /> Owner Name `, 'r�'�� Add ss <br /> Phone <br /> Contrat Addres3�iEense N 6 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well O <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 /> CI 190ustrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> PT-Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ublic 1"-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth 1 Eastern1,5urfacs Seal Installed by M <br /> Repair Work Done 11 Type of Pum H.P. Y State Work Done <br /> Well Destruction O Well Diameter Sealing Material li Depth C? <br /> Depth Filler Material i Depth Q <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 vWI serve: Residence— Commercial_ Other t <br /> Number of living units: Number of bedrooms <br /> Character of sol to a depth of 3 fist: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line Z <br /> LEACHING LINE 0 No. b Length of lines <br /> Total length/size <br /> FILTER BED O Distance to nearest: Wall Foundation Property Line <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 1 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, 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion lata of California." <br /> The applicant c r aB require inspections. Complete drawing on verse side. <br /> Signed Title: --- Date: 3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date `3 +�I6 <br /> Arba <br /> Pit or Grout Inspection by Date Final Inspection by ate <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, 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> ,,INFO �^ RECEIVED By DATE pPERM,I,T�'NNOO..EM 13-24 ,� <br /> • EH 14-35II1EV,r i n 51 T t!J [SN-3 F . ?3—OV ;, <br />