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APPLICATION FOR PERMIT <br /> 4 �I SAN JOAQUIN COUNTY PUBLIC HEALTH SIMVICES <br /> p � ENVIRONMENTAL ,HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YM FR M DATE ISSUR-D <br /> (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> 1 application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ^� <br /> Joaquin County Public Health services. . 15PAI <br /> City Lot Size/Acreage <br /> Job Address <br /> Owner's Name <br /> 1,01[ Address •n Phone <br /> ._, ) <br /> Contractor <br /> Address icense No­2WZZZ1--!> Phone � <br /> TYPE QF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out Won toring well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK - —SEWER LINES-;, T _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Wall Casing <br /> n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation_ f <br /> Type of-Casing Specifications —\ <br /> fa DomesticlPrivate C7 Gravel Pack ❑ Tracy g Type of Grout v <br /> I'1 Public Cl Other 1-1DeltaDepth of Grout Seal <br /> t I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> I Repair Work Done D Type of Pump H.P. State Work Done <br /> Weil Destruction Well Diameter 42 <br /> Sealing Materiel i Depth <br /> Depth Tiller mate jai i Depth 19 04U <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADOITION I I DESTRUCTION I I (No septic <br /> able system <br /> ithin m feett)ed if public sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: _ Number of bedrooms w <br /> Water table depth <br /> Character of soli to r depth of 3 feet: <br /> k SEPTIC TANK' ❑ Type/Mfg Capacity Na. Compartments <br /> f PKG. TREATMENT PLT. 0 Method of Disposal <br /> + Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE Cl No. 5 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well .,,Foundation `Property Lina <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> � DISPOSAL PONDS � <br /> ill be done in accordance with San Joaquin county ordinances, stats laws, and <br /> I hereby canify that I have prepared this application and that the work w <br /> rules and regulations of the San Joaquin County <br /> fy that in the performance of the work for which this perriiit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certi <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 companies- <br /> tion laws of Califo► la." <br /> The applic call for Ali required i ions. Complete drawingo raver aid <br /> Signed Title: Date: /a <br /> FO DEP SE-ONLY <br /> Application Accepted by2. <br /> Date A , <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . <br /> EN13-24 111EV.t i M b 1 I_ <br /> =1—p &fz /L--if <br /> EH 14•76 r✓ <br />