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APPLICATION FOR PERrdIT <br /> _ JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL 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 I$SUM <br /> 4 ' <br /> (Complete in Triplicate) <br /> Application is ereby made;Lo San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in cot�liance vith San Joaquin County Ordinance No. 549 and 1962 and the Aides and Regulations of San <br /> Joaquin County Public health 8ervicee. <br /> r /O <br /> Job Address LVCT �40 City C Lot Size/Acreage _ <br /> 1� <br /> Owner's Name 0 Address Phone <br /> Contractor Address � � License No.37?3�s Phane33y Y71- <br /> TYPE OF WELL/PUMP: NEW WELLW WELL REPLACEMENT ❑ DESTRUCTION o Out of Service well ❑ ` <br /> PUMP.INSTALLATIONg SYSTEM REPAIR CI OTHER O Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPT�IC TANK SEWER LINES DISPOSAL FLO. PROP. LINE /So <br /> FOUNDATION AGRICULTURE WELL `-OTHER WELL. -�� PITS/SUMPS r <br /> i <br /> INTENDED USE TYp;E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } <br /> C7 Industrial ❑ Opan Bottom ❑ Manteca Dia. of Well Excavation _ [ Dia. of Well Casin ' <br /> k `/��/� Specifications 4VTO <br /> -YDomestic/Private VieGravel Pack 0 Tracy Type of Casing — <br /> T <br /> l'I Public Cl Other fl Delta Depth of Grout Seal sa Type of Grout <br /> t I Ifrivation 3 Approx. Depth 14 Eastern Surface Seal Installed.by, �; c ~ <br /> Repair Work pone : C3 Type�'f Pump. 5 u� H.P. S State Work Oona rnA A�O { <br /> Well Destruction ❑ well Diameter Sealing Material i Depth v 1 <br /> Depthl Filler Material 4 Depth tT <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is <br /> .I _ available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other r <br /> Number of living units: <br /> K� Number of bedrooms r O <br /> S C <br /> Character of twif to a depth ofl3 feet: Water table depth G <br /> SEPTIC TANK. ❑ Type/Mfg r Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ �� Method of Disposalkr <br /> F <br /> Dtstance to nearest: Well t Foundation .Property Line <br /> 4 I ; <br /> LEACHING LINE Cl No. & Length'of lines Total length/size <br /> FILTER'BED t f CJ Distance to nearest: Well Foundation Property Line <br /> SEEPA4E-PITS I I Dle�pth Size Number, 3 <br /> SUMPS Ll 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 Ssn:�Joaquin County I . <br /> Home owner or licensed i ent's1`"' n"slurs certifiss-the•followin I Certify.that.in the rformance of the work for which this permit is issued:I shall not <br /> f7 erg g .. <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 /> candies the following: "I certify t#tat in the performance of the work for which this permit is issued, I @hall employ persons subject to workman's compensa- <br /> tion laws of Csllfoirnla." <br /> The applicant must call for an F"uired inspections. Complete drawing on reverse side. <br /> Signed X. Title: a ti<rX Date: <br /> F R DEPARTMENT USE ONLY <br /> i �c ^} i <br /> Appiicatlon Accepted by Date y X-` —00— Area <br /> . <br /> Pit or f3rouK Inspection by "I Date 1 V Final Inspection by' pate/x'?Z-q y- <br /> Addhionnaalll Comments: <br /> i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 f\ <br /> INfO AMOUNT DUE AMOUNT REMITTED t CASCK H RECEIVED BY DATE PEMIT'R <br /> ` . EH 1124(REV. i ra @) <br /> '� 'N 3 r 1-217 <br /> F EH 14•x@ f <br /> �I <br />