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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IfI <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES 1 YEAR FRQM DATE ISSUBP <br /> (Complete in Triplicate) <br /> Application is hereby made,to Baa Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance With San Joaquin County ordinance No. 51+9 and 1862 and the Rules and Regulations of San s <br /> Joaquin Coun Pub is Nealth Se ices. <br /> City Let Size/Acreage <br /> Job Address � - <br /> Qb <br /> Md ess ` Phone <br /> Ow, is Name ,/� <br /> DaY�l Address Ct? ne`1 . <br /> actar <br /> TYPE OF WELLIPUMP: { NEW WEL EJ WELL REPLACEMENT n ' DESTRUCTION 0 Out of Service Well ❑ <br /> OTHER ❑ 'al4onitoring well C]PUMP INST,ALLATIOIy/T3�� SYSTEM REPAIR ❑ - T <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSI-SUMPS-7= <br /> INTENDED USE TYPE?OF'WELL PR06LEM AREA CONSTRUCTION SPECIFICATIONS r <br /> n dusuia1 0 Open'Bottom ❑ Manteca Die. of Well Excavation ^- Dia. of.Weil Casing <br /> V •� Specifications <br /> stic/Private 0 Gravel Pack 0 Tracy Type of Casing_ P <br /> i"I Public fl Other n Delta Depth of Grout-S'elil""'� ~'" ! Type o - rout--��••^- <br /> I 1 Irrigation Approx. Dept l I stern Surface Seal Installed by <br /> ' Material 4 Depth Sealing _ ne <br /> Repair Work Done U Type of iPuri'ipH.P. ,� --- <br /> State Work <br /> Well Destruction 0 Well Diameter Scaling <br /> Depth l Piller Material i Depth — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system Perm <br /> ined if public cower is <br /> �availabie_vrit#tin_2f10_feat•! _ - <br /> 't <br /> Installation will serve: Residenco— Commercial Other x, <br /> Number of living units: Number of bedrooms - <br /> Character of soli to a depth of 3;feet: Water table depth �~ <br /> I SEPTIC TANK. 0 Type%Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> owu'rice to nearest: Well` Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> V' <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Wall Foundation Property Line <br /> DISPOSAL PONDS 0 ALI <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 "a <br /> fy that in the performance of th's work for which this permit 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 beaomaa ubp_ct_ta�vork�la�'a ortlRellsaiion.la�ncs of_Cal true+:fir t[asio[a hiring or sub-contracting signature <br /> canifiaa the following: "I certify thar•in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss <br /> tion laws of California." <br /> The applica st Ceti uirad ' sp .ctions. Complete drawing on e eras si <br /> 7b <br /> T Date: IU- <br /> Sig , <br /> ,,FOR DEPARTMENT USE ONLY <br /> k Application Accepted by <br /> � (/► d+ Date Araa /[ <br /> Ph or Grout Inspection'by Date Final Inspection by <br /> ZT Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County publi-a_Health Services <br /> Environmental Health Permit/bervices. <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'IVO. <br /> I F (� ( <br /> ` EH 13.24(REV.,.tie) t �lr � O / U <br /> fH 1476 <br />