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APPLICATION FOR PERMIT /0 CJo <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 4 BO% 2009, STOCKTON, CA 95201 Fy , : <br /> , r . <br /> PENIT EXPIRES I YF <br /> AR FROM DATE S <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 eow�liance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health� Services. <br /> ZQ 42L S CityAL&ALI+Llt Size/Acreage <br /> Job Address <br /> Owner's Name Address • ' — Phone <br /> Contractor t- h Address ' icense No. Phone <br /> TYPE OF WELL/PUMP: is NEW WELL ❑ WELL'REPLACEMENT rl DESTRUCTION L-1out of service Monitoring we <br /> O <br /> PUMP-INSTALLATION ❑ .,SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUN 10�`�A�RIClJLTUAE-4YEL"L'_OTHER'"WEL"l P1757StJiiAP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ DomestielPrivate ❑ Gravel Pack n Tracy Type of Casing_ Specifications ® i <br /> I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation w.Approx. Depth 1 4 Eastern Surface Seal installed by p <br /> ,Repair Work Done Ll Type f Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter 1 Sealing Material i Depth` <br /> ' <br /> DepthlM ! tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 RUCTION i I (No septic system permitted if public sewer is <br /> 11 .Z— j available within 200 toot.) <br /> t i <br /> Installation will serve: Residence.'_LA4--eommercialOtltier " <br /> Number of living unite: 11Number of bedrooms 'v� J k ,r -I <br /> Character of MA to a depth of 3 feet: -&,h f h - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ t Method of Disposal <br /> Distancet to nearest:' Well Foundation Property Line - f <br /> tet nth/size <br /> LEACHING LINE ��I Length of lines g <br /> FILTER BED n Distance to nearest: Well ' Foundation Property Lina <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest! well , ' Foundation Property Line <br /> l DISPOSAL PONDS ❑ �N �' J <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..lews, and M <br /> rules and regulations of the Sen,Joaquin County 1�1 <br /> Home owner or licensed agent's signature Certifies ilia folld`wing: "1 certify that 1 —the 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 following: -I certify that in the performance of the work for which this permit is isued, I shall employ persons subject to workman's compensa <br /> tion of Californ --- <br /> F The applice u tail for t irad do a draw" <br /> S Date: <br /> I FOR DEPARTMENT USE ONLY{ <br /> f I e6 Q Z—} <br /> Application Accepted by r Date <br /> I :, r s► <br /> Pit or Grout inspection by I� Date Final Inspection.b! Date <br /> t Additional Comments: �" t <br /> i Applicant - Return all copies to: San Joaquin County Public Health Services <br /> &avironmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009,. Stkn, CA 95201 <br /> I � ` <br /> I FEa NT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PFRMIT NO, <br /> F INF (' <br /> CH 13-24 CP <br /> EH t1.1e Ir1EV.Iis<al � � �a r���� , ��, <br /> M <br />