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y APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> o ENVIRONMENTAL HEALTH DIVISION k, f <br /> 5. <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 r <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 work 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 County Public Health Services. <br /> Job Address .S '''1 r1oa✓` d S111 City Lot Size/Acreage <br /> Owner's Name iA,k. Pig �_ Address l/ 0N` Piton <br /> 1 11.1 // 2 =3zz z <br /> Contractor Address S' � � License N TS���Phon <br /> TYPE OF WELL/PUMP: N W WEL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O / SYSTEM REPAIR O OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> ->00 /' <br /> LINES 2®© DISPOSAL FLD. PROP. LINE-o?%-'Cr� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — V <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L-1 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> m � V" <br /> [:l Doestic/Private .Graysl Pack O Tracy Type of Casing_ V�/L i Specifications.. <br /> I'1 Public Cl Other��p/ n Delta Depth of Grout Seal pe of Grout <br /> '�4Jrrigation -- pprox. Depth I I Eastern Surface Seel Installed byX& C <br /> Repair Work Done Ll Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material A Depth <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 will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fast: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. b Length of lines Total length/size O <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 w licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall notes <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 at call for all required ins tans. Complete drawing on re erre side <br /> � rr C <br /> Speed X / G � �� � Title: rte„( Date: <br /> FO DEPARTMENT USE ONLY �1 <br /> Application Accepted by Date or Area <br /> Pit Grout tion by Dat- Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services 1 <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOjUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT'N0. <br /> . 1 <br /> EN U-24 111EV.l i n 9l ,� 13M h g <br /> EM 14-M V I .).-to 31 <br />