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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /0 3d ' <br /> r� ENVIRONMENTAL HEALTH DIVISION <br /> dol 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> HERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �/_,,[[ _ <br /> Job Address �! 7'3 (' ��� '`�'� City X�C'�'Lot Size/Acreage <br /> Owner's Name ��� y " )Q/1lt2L &eP2 ddress 77 Phone <br /> Contractor Address 01-52 ' el` ense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT O DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well O <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 SPECIFICATIONS r <br /> ❑ Industrial O Open Bottom O Manteca Dia. of Well Excavation 2 ` Dia. of Well Casing � <br /> �0 Domestic/Private )0 Gravel Pack7 O Tracy Type of Casing_ PUI� Specifications <br /> Il Public Cl Jqther n Delta Depth of Grout Seal Type of Grout &- <br /> I I Irrigation -1)4bApprox. Depth I I Eastern Surface Seal Installed by C14-/ <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> We" Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth \ ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is �1�F <br /> available within 200 feet.) <br /> Installation will serve: Residence e Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 6 Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that 1 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 /> Hone owner or licensed agent's signature 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 of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of C fornla." <br /> The applican st call for ail r ed inspections. omplete drawing evefs;�o. <br /> Sigma ZC Title. Date: <br /> EP TMENT USE ONLY Q <br /> Application Accepted by ' k. Date �\^\ 1l � Area <br /> PitGro' Inspection by ata Final Inspection by Date <br /> Additional Comments: <br /> 7r- 16 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I K a RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EN 13-24 111EV.i i h 51af 1 <br /> EH 14.20 \��••J// <br />