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APPLICATION FOR PERMIT <br /> �. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMMTAL 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 /> i ��f=� � ' ' ► .• (Complete in Triplicate) <br /> 041-7-o,*O-z-z_ <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 vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Phone <br /> t <br /> Contractor dress License No. <br /> q&a Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17.1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION b SYSTEM REPAIR OTHER ❑ 14onitoring 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 /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Weil Casing <br /> [I Domestic/Private O-Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I I'1 Public 1:1 Other n Delta D f Grout Seal Type of Grout <br /> rrigalion _Approx. Depth 1 I E stern eurfac Seal Installed by I r } I <br /> Repair Work Done 0 Type of Pump H. State Work Done { 1 <br /> Well Destruction O Well Diameter Se rial i Depth. <br /> Filler Naterial i Depth <br /> Depth p <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION I I DESTRUCTION 11;INo septie'system permitied il'publie sewer is' <br /> available within 200 feet.) },c .'' <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soft to a depth of 3 fast: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity t 4 I No. Compartments <br /> PKG. TREATMENT PLY. ❑ s { MetFi d of Disposal <br /> Distance to nearest: Well Foundation Pr E <br /> operty Line- <br /> LEACHING <br /> ineLEACHING LINT Cl No. b Length of lines Total IengtFi/size <br /> FILTER BED ❑. Distance to nearest. Well Foundation €Property Line <br /> SEEPAGE PITS I ) Depth Sizeti ,-Number <br /> SUMPS <br /> ❑ ZLDi tance to neorest' WalI Foundation Property Line 1 <br /> .DISPOSAL PONDS a #" <br /> 1 I <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 , 1k , t ' I J _ !_ , t <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;I Mall not ; <br /> tirrtploy any parson in such manner as to become subject to workman's compensation laws of California.- Contractor's hiring or"sub contracting.signature <br /> `cirtifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject'to workrnari's compenss- <br /> tion laws of California." s '. -+ — f r -J + f {( <br /> The applies n ' a requir I ns. Complete drawing on raver side. <br /> Signed Title: o ' Date« ' <br /> .- -- <br /> ',moi: <br /> �OR DEPARTMENT USE ONY j ?, <br /> Application Accepted byVG� A � Date � Area <br /> ' <br /> � <br /> Pit or Gr'but Inspection by Date Fins] Inspection by r Date <br /> Applicant - Return all copies to: 'Sin Joaquin County Public•,Health Services 71. <br /> EnViranmental Heal* Permit/Servicee, �, y� <br /> 445 N San Joaquin; P:O'Box,,2009,�Stk"n, CA 9520I "," C � <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY Z'pATE PERMiT'NO. <br /> ER'112�"IREV.1 'e'61..P,(7 - ^' 10 s Q� _ rO w. ^.-f�`6 � <br /> EH 14.26 C` <br />