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APPLICATION FOR PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> G 445 N SAN JOAQUIN PHONE (209)46$-3420 <br /> P O BOX 2009 <br /> U <br /> `� , STOCKTON, CA 95201 <br /> Nov ILI <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN joAQtj CO Z <br /> (Complete in Triplicate) ,PLIF30C HFAL711 �_ � � <br /> EN1V1l 0N-V!ENfT 1 � €� ER ICES <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein descri-bectk'Fr1i".V1"f,aN <br /> application is made in compliance 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 � -` CitLot Size/Acreage <br /> Owner's Name " Address `w � �1.�. ._____ Phone '` ! <br /> ConIracI.or,A -�t& Address R0, License No. Phone <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br />• PUMP INSTALLATION 5. SYSTEM REPAIR OTHER ❑ 14onitoring Well <br /> UISTANCE-TO-NEAREST:=SEPTIC-TANK.-�---=f =-SEWER-LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS'" u <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ois. of Well Casing <br /> be Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> Il Public n Other fl Delta Depth of Grout Seal - Type of Grout <br /> I I Irrigation —Approx. 0 ih I I E tern Surface Seal Installed by <br /> Repair Work Dane Type of Pump H.P. _ Statq Work Dona <br /> Well Destruction O Well Diameter Sealing Material i Depth — 2.d <br /> Depth Filler Material i Depth 1 <br /> s <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION [ I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feel,1 <br /> Installation will serve: Residence— Commercial— Other 'w � J�J •�•+�'� <br /> Number of living units. Number of bedroomr <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 /> a <br /> Distance to nearest; Wel Foundation __ Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size 1 <br /> FILTER BED ❑ Distance to nearest: Well 4 .;Foundation. Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> Ll—Distan-ce to nearest: �Wall '^ Foun`datlon�-—'Pro <br /> petty Line— <br /> DISPOSAL PONDS ❑ <br /> I 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'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 follows I certify that in the performance of the work for which this <br /> following:" fy ps permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> i <br /> The applicant must call for all required inspections. Complete drawing onver a side. <br /> Signed X Title: m ft/ Date: <br /> FORD ARTM PW U <br /> Application Accepted by C�7 <br /> ate � tea ' <br /> Pk or Grout Inspection by Date Final Inspe tion Date�� . <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services j <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ATE PERMIT NO. <br /> INFO <br /> i <br /> . Est 13.2 (REV.r/It 5) co <br /> Eli i4•2(f <br />