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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES R PROM <br /> (Complete is Triplicate) <br /> Application is hereby meds to Sane Joaquin County for a Permit to construct and/or Install the vork herein described. This <br /> application is made in conwilancevith San Joaquin County Ordinance No. 549 and .1862 and the Rules and Regulations of San <br /> Joaquin Corday Public Health Services. f <br /> Job Address d fib City�i�; Size/Acreage <br /> � Lot <br /> Owner's Name n 4t CA- Address k Phone — 0 <br /> GantractIr�.!� t} Address License No. 4 2— Phone y <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 SPECIFICATION94' <br /> 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavali n Dia. of Well Casin <br /> Domestic/Private Gravel Pack. Tracy Type of Casing Specilications <br /> I7 Public f-1 Other t- ❑ Delta Depth of Grout Seat -_ � Type of Gut o ` <br /> CI Inioation .._._ Approx. Depth ❑ Eastern Surface Seal Installed by •�' <br /> Repair Work Done U Type of Pump H.P. &Work Done_ <br /> Weft Destruction O Well Diameter r Sealing Material 4 Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK:. .NEW:INSTALLATION 0 REPAIR/ADDITION ZI DESTRUCTION CI (No septic system permitted if public sewer is j <br /> available within 206 feat._) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms w <br /> Character of soil to a depth of 3 fest: Water table depth <br /> SEPTIC TANK 0 type/Mfg f Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number w , <br /> SUMPS Ll Distance to nearest: Welt 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: 1 Certify that in the performance of the work for which this permit is issued, I shell 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 issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant sf 11 foroall reciAir inspoctiona. Complete drawing on rev aside. <br /> Signed 3 <br /> 9 Title: —_/ Bats: ,� ��)�;���5_ � <br /> DEPARTMENT USE ONLY <br /> Application Accepted byED, 1 <br /> - QrA.." Data - Area ' <br /> Pit or Grout Inspection by Date Finaf Inspection by ' pate /f <br /> Additional Comments: <br /> Applicant - Return all copies to: ! <br /> P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH <br /> RECEIVED 8Y DATE PERMITNO, I <br /> . EH i34111tEY.�/MSi � I' <br /> tiH',l,ia <br />