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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 EXPIRES 1 YEAR FROM DTE SU <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 San Joaquin County Ordinsnce No. 51+9 and 1$62 and the Rules and Regulatione of San <br /> Joaquin County Public Health Services. <br /> Job Address _� / A ,leek'" City Lot Size/Acreage 3© 4n,,e-' <br /> Owner's Name '441tty Address Z d awL` S �TQ'phone Q <br /> t k !g dress l 4ii eyxie & A <br /> Contractor u j r n vt O License Nn.fF_2J.5Sgr _Phon 2-/ 2 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT><_ DESTRUCTION 08CPut of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM RYPAIR ❑. OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK " :�t SEWER LINES DC7 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL .-Z PITS/SUMPS �— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private f:jaraval Pack ❑ Tracy Type of.Casing— �C Specifications <br /> V] Public ` -I Other n Delta Depth of Grout Seal ice_ TZ of Grout —� <br /> I I Irrigation -jilFa4pp(ox. Depth I I Eastern Surface Seal Installed by ++c u+ +� <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Wall Destruction NL Well Diameter <br /> Sealing Material i Depth <br /> Depth -3 Filler Material i Depth <br /> TY EP IC WORK: NEW 1 STALLATION l I REPAIR/ADDITION I I DESTRUCTION E 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&oil 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 0 No. 3 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordarice with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Son Joaquin County <br /> Home 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 sub-contracting 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 for all required inspections. Complete drawing on reverse side. <br /> t <br /> Signed Title: �G V, - _. Date: , 5� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by (LA ftea n Date ����Z_ Area Q <br /> Pit or EoutOspectlon by Date la di Final Inspection by Date <br /> i <br /> Additional Commenu: <br /> Applicant - Return all copies to: an Joaquin County Public Health ervices <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CA H(r RECEIVED BY DATE 9PERM17'NO. <br /> F ES 1��4 IREV.I/R V W Z <br /> •f�0 �� �b l O�� �^ <br />