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APPLICATION FOR PERI[I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> • P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FRQM <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described This <br /> application is Stade in ec>agsiianee VIth Baa Joaquin County Ordinance Ro 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> Job AddressCity SfVC�C?7t-2-) Lot Size/Acreage <br /> �l C�f�a �O Dio -77 &.P"C2!!64C�.l.J(o� lnly��4,C �Pr4�+�J�7)Phone/ - <br /> wner s Name �[ ��.�� d `�/7 <br /> Contractor �1 �(Attdrt�s� QOX 3� cense No Ph?( <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .7, 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 SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing <br /> 171 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing Specifications <br /> I 1 Public r 1 Other (-1 Delta Depth of Grout Sealer Type of Grout G4�� <br /> I I Irrigation ____Approx Depth l I Eastern Surface Saul Installed by <br /> Repair Work Done 0 Type of Pump H P State Work Done _ <br /> Well Destruction ❑ Wap 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 (No sepuc system permuted it public sower is <br /> available within 20D lest I <br /> Installation wdl serve Residence_ Commercial_ Other <br /> Number of Irving units Number of bedrooms <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacs No Compartments <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE ❑ No 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS It Depth Sue Number <br /> SUMPS Ll Distance to nssrest Well Foundation Property Lina <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, slate laws, and <br /> rules and regulations of the San Joaquin County <br /> Home 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 shalt not <br /> employ any person in such manner as to become subject to workman s compensation laws of California ' Contractors hiring or sub-contracting signature <br /> certifies the following "I certify that in the performance of the work for which this pernut is issued I shall employ persons subject to workman a compensa <br /> tion laws of California- <br /> The applicant must call for all raquirsd in s C a ra Ing on reverse side <br /> r <br /> Signed /s��erg �i.r� Trtle `✓ Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ _ -- - Date 14(0-72' Area _ Ort t * r <br /> Pit or Grout Inspection by Date Final Inspection by Dote <br /> Additional Comments <br /> Applicant - Return all copies to San Joaquin County Public Health Services <br /> Boviroamental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stka, CA 95291 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED rr CASCK H RECEIVED <br /> � BY DATE 7 PERMIT_NO <br /> t}2�I1tEV ti�si �O. fr}� �� k l rs��' l J tto-Ctf 2, 2-Z5q( <br />