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r <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 /> j P 0 BOX 2009, STOCKTON, CA 95201 <br /> {PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ApplicRtion is hereby alade to SanlJoaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coWliancelvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public <br /> )J Pealth pervices. <br /> Job Address 4 , City Lot Size/Acreage <br /> vlo,. ALaC !ar, ams �7 dress i �_ Phone <br /> or�°fl1A- �cJ 4ljdg —, res License Na �1 —Phone.I r �� <br /> &&LTV <br /> TYPE OF WELL/PUMP: NEW MiL ❑ WELL REPLA8EMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> 1) Ifdustrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> Pamestic/Private Cl Gravel Pack* ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public ?. Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Dept I I astern Surface Seal Installed by <br /> Repair Work Done 0 i Type of Pump H.P` 5 _ State Work Dan <br /> Well Destruction O Well Diameter��-s Sealing Material i Depth <br /> 4-.0epth 2Filler _Material & Depth 1 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 11, DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> f available within 200'feet.1 <br /> installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms o <br /> Character of sob to a depth of 3 fest: Water table depth *�7 <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT:❑ Method of Disposal <br /> ' <br /> Distance to nearest: Well Froundation — Property-Line- <br /> LEACHING <br /> ropertyLine-LEACHING LINE Cl No. & Length of lines Total length/size F <br /> FILTER BED ❑ Distance to nearest: Well Foundation.---=--Property Lins k ' <br /> SEEPAGE PITS l I Depth �"S a r - `� Number <br /> SUMPS L1 Distance to nearest:�. Well aundati6n Property Line <br /> DISPOSAL PONDS ❑ . <br /> 1 hereby certify that I have prepared this application and that the work will 4er one in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County `s <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, 1 shall not <br /> employ any person in su 'h manner as to become subject to-wbrkman's compensation laws of California."Contractor's hiring Or subcontracting signature �- <br /> certifies the following: " ertity that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of Ifornle <br /> a� <br /> The appl t tint-tali f requir inspections. Complete drawing on rover ide. <br /> Sip Title: Date: <br /> f R DEPARTMENT USE ONLY <br /> Application Accepted by C.A, � _ g{�yy Data ® � Area <br /> Pit or Grout Inspemio,5by ] Date Final Inspection by Date r 7� <br /> Additional Comments: C <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Hnvironmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT Dill: # AMOUNT REMITTED K RECEIVED BY ATE PERMIT NO. <br /> r <br /> . EH 13-24(REV.t/1151 Rio r / - Ile <br /> Ek 14.21 O � <br />