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APPLICATION FOR PERMIT <br />' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Wt ENVIRONMENTAL HEALTH DIVISION <br /> f 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 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 c012111iliance 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 lj5 -5 .Sc� g/' <br /> CityA?ge Got Size/Acreage <br /> Owner's Nam Address 'D Phone 2o?_Bro� <br /> F ContractorAddre ( -Al 31�13 ���G'�rj�F'Q 4/1 <br /> License phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT {1 ., DESTRUCTION 0 Out of Service well Cl <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ ,4 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 /> L-1 Industrial ❑ Open Bottom ❑ MantecaDia, of Well Excavation Dia. of Well Casing <br /> f1 Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing_ Specifications <br /> I'I Public I'1 Other f1 Delta Depth of Grout Seal Type of Grout 0 NK <br /> I l Irrigation •w Approx. Depth l I Eastern Surface Seal Installed by �. <br /> Repair Work Done 0 Type of Pump M.P. State Work Done, <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> ;. Depth Tiller Material Ile Depth ! <br /> t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted it public sewer is (A <br /> Installation will serve: Residence_ Commercial..� Other (A <br /> available within 200 lest.) <br /> Number of living units: Number of bedrooms <br /> Character of SOO 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 /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No, & Length of linea Total length/size 4 <br /> FILTER BED ❑ Distance.to nearest:.. _ Well Foundation Property Line <br /> M <br /> SEEPAGE PITS 1 1 �,A I <br /> Depth Size Number -� <br /> SUMPS 11 Distance to nearest: Well Foundation Property 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&hall not <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 shop employ persons subject to workman's compensa- <br /> tion lawn of California." <br /> The applicant m st w11 Par all required inspections. complete drawing on averse side. <br /> Signed Title: .'/ <br /> a e� <br /> J FOR DEPARTMENY USE ONLY 15"1 <br /> Application Accepted by +�'� Date ` Area <br /> Pit or Grout inspection by onhb date Final Inspection by <br /> Date <br /> Additional Comments; /7' — # <br /> Applicant - Return all copies to: San Joaquin County Public Health Services 61 <br /> Q�✓✓✓� <br /> Environmental Health Permit/Services `)Ro ' <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 666 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATEEN PERMl7 Np. <br /> INFO / ` yy,Cl!ASH Q�r �] <br /> � EH1�mfREV.lies� f n° ! $1 'I� ►u' 'd� 5 <br />