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APPLICATION FOR PER1M I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES + <br /> r ENVIRONMENTAL HEALTH DIVISION T <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 ' " • <br /> Y R .rr <br /> (Complete in Triplicate) <br /> Application is hereby made to Sax Joaquin County for a Permit to constructand/or Install the work herein described. This <br /> application is made in c� nce:No.liance With San Joaquin County Ordina549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> t <br /> Job Address71 <br /> _� "1 <br /> l City . Lot Size/Acreage <br /> Owner's Name It> u_ - rp�f <br /> Address �Q Phone —9l 6 <br /> • Contractor-nt/."".z. - Address <br /> TYPE OF WELL/PUMP: 6'License No. 3 + ." Phone <br /> NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ,BOTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST:'SEPTIC TANK _ SEWER LINES C7 <br /> ---�� DISPOSAL FLD, PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATLONS l <br /> El Industrial ❑ Open Bottom ❑ Manteca '— pia" of Well Excavati n <br /> Domestic/Private Dia. of-Well Casing >1 <br /> 54 1 Gravel Pack 7-CR Type of Casing <br /> M Public I'1 Other --t-�=-- Specifications <br /> 111 ❑ Delta Depth of Grout Seal Type of Gro t r . <br /> Ci Irrigation ­Approx• Depth ❑ Eastern Surfaco Soul Installed by <br /> Repair Work Done U .Type of Pump H.P. t <br /> Well Destruction p Well Diameter Sealing Material A Depth State Work Done :I <br /> DepthFiller Material 4 Depth �•t vrr lug ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ flEPAiRlAODITlON Cl DESTRUCTION CI .iNri septic System permitted if public Nv f <br /> sewer is <br /> Other <br /> Installation will serve: Residence— Commercial available within 200 feet,} <br /> �... I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feat: T <br /> SEPTIC TANK. O Type/Mfg Water table depth <br /> PKG, TREATMENT PLT. Cl Capacity No. Compartments <br /> Method of Disposal <br /> Distance to greet: Well Foundation _ Property Line i <br /> LEACHING LINE L-1 No. & Length'of lines <br /> FILTER BEDTotal length/size <br /> [] Distance to nearest: Well Foundation_ Property Line �. <br /> f <br /> SEEPAGE PITS f I Depth # Site -•.. <br /> Number <br /> SUMPS <br /> Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS p Property Lina <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 taws, and f <br /> rules and regulations of the San Joaquin County <br /> Home owner of licensed agent's signature oertifisi the fotlowtng: "I certify that in 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 I� <br /> certifies the following: "I certify that in the performance of the work for which this I <br /> 'tlon laws of California." permit is issued, !shall employ persons subject to workman's compensa• <br /> Thea applicant!Ap it forp1l rVO.l inspections. Complete drawing on re rse side.' <br /> Signed Title: <br /> Date: <br /> 0 EP ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout inspection by pate <br /> -�_ Final Inspection by pate <br /> Additional Comments: t Y + <br /> Applicant - Return a" SA <br /> Copies to: Q ' <br /> P N J OA UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ,f„ �_ <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE girl <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH FIECEIVED BY GATE <br /> PERMIT NO. <br /> EH *,24 IM.iin51 <br /> fH 74•20 69 `� <br />