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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE IsD <br /> (Complete in Triplicate) <br /> Application In hereby made to San 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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> t Job Address �( .�C��� �_ City Ldp ? Lot Size/Acreage <br /> Owner's blame _ � ///�i(/LCd.� Address � 4y",_ Phone <br /> - t <br /> Contractor Address —Act.6441 License No.r70 ?.T✓ Phone 2 C-F <br /> TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> .i <br /> DISTANCE TO NEAREST: SE71C TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> , <br /> INTENDED USE TYFPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack "D Tracy Type of Casing_ Specifications <br /> 1'1 Public 1-1 Other f-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U TypeofPump H.P. State Work Done_ <br /> Wall Destruction ❑ Well DiameterSealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION il'DESTRUCTION I I (No septic system permitted if public sewer is <br /> '', r/ available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: I� Number of bedrooms 3 <br /> } Character of sod to a depth of 3 feet:.• " d r <br /> ---�--�-r't"+"�`A �� �,� Water table depth <br /> -v SEPTIC TANK ' T /Mtg - @6' - iE] d—C—. Capacity--l-4.1 No. Compartments �Z— <br /> PKG. TREATMENT PLT.© I Method of Disposal <br /> Dimance to nearest: Well /rte } <br /> � Foundation —__/0 Property Line__lgz � <br /> LEACHING LINE P11'No. & Length of lines !Z Total langth/size I <br /> r <br /> FILTER BED ❑ Distance to nearest: Well .f PD r Foundation Property Lina -5- <br /> SEEPAGE <br /> SEEPAGE PITS 14—D!,p th Siie .___3G� Number <br /> SUMPS LI Distance to nearest: Well 1:2G _ Foundation O t Property Line -5 f <br /> DISPOSAL PONDS ❑ Il r <br /> I hereby certify that I have prepared-ks application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the SanlJoaquin County <br /> Home owner or licensed agent's.iignatum certifies the following: "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 <br /> certifies the following:"I certify that in the performance— -: - 4- --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 applica st call for an r Iq 'ad i coons. Complete drawing on reverse side. <br /> Signed ' TitIo: Date: <br /> y r FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date JF) -$' I _ Area <br /> Pit or Grout Inspection b � Data Final Inspection by <br /> Additional Comments: o <br /> Applicant - Return all copies to: San Joaqu n County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNIT DUE AMOUNT REMITTED AS CEIVED BY DATE PERMITNO. <br /> + EH 14,24 1l1EV,11"504 <br /> I:H lade i (J <br />