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I APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 'EWVIRONMENTAL HEALTH DIVISION <br /> 445 .N',-SAN JOAQUIN, PHONE (209)468-3420 <br /> i P "0 BOX 2009, STOCKTON, CA 95201 <br /> i <br /> PERMIT E%PIRRR 1 VRAD FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APplication is hereby msAe to San Joaquin Coun <br /> tv for a <br /> application is Slade in compliance with San Joaquin County Ordinancermit to nNoruct 51+9asndo1862$tall and thee work Rules and ein Hegulationadof Sans <br /> Joaquin County Public Health Services. <br /> ' Job Address <br /> Cit 1=0 lY���` <br /> Got Size/Acreage <br /> c <br /> Owner's Name r Address <br /> .V7 9Z one ccJ <br /> F,iGeo'. <br /> Contractor t Address <br /> License No. phone <br /> TYPE OF WELL/PUMP: NEW WELL'S WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service;:Well '0 <br /> PUMP INSTALLATION p ; <br /> SYSTEM REPAIR ❑ <br /> OTHER Q Moriitor3ng 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 /> -I 0 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation <br /> 1] Domestic/private ❑ Gravel Pack ❑ Trac T Dia. of Well Casing <br /> Y Type of Casing_ Specifications 4� <br /> Il Public [I Other fl Delta Depth of Grout Seal <br /> 14 i 1 IrrigationType of Grout; <br /> A C' <br /> pprox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done - 0 Type of Pump H p ' <br /> State Work Done <br /> i Well Destruction . 0 We#Diameter Sealing Material a Depth <br /> Depth Filler Materlal & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION I 1 DESTRUCTION I 1 fNo septic system permitted if public sewer is <br /> I Installation will serve: Residence Commercial available within 200 feet.} . <br /> Other <br /> `Ei 1 Number of living units; Number of bedrooms <br /> Character of$04 to a depth of 3 feet: <br /> SEPTIC TANKWater:table depth <br /> PKG. TREATMENT PLT.❑ <br /> ❑ Type/Mfg _ Capaci1V No. Compartments <br /> Distance to Hearse;; Method of Disposal <br /> Well Foundation <br /> Property Line <br /> F f LEACHING LINE ❑ No. 3 Length of lines <br /> FILTER BED Total length/size <br /> C] Distance to nearest: Wail Foundation Property Line <br /> i SEEPAGE PITS I I Depth Size <br /> LI Distance Number <br /> _ stsnca to neatest: Well Foundation a ' DISPOSAL PONDS p ----- Property Line <br /> F <br /> i hereby candy 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: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> _f Onnpioy 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 <br /> tion laws of California.,, permit is issued, I shall employ persons subject to workman's companaa <br /> ' The applicant t call fore required inspections..-Complete drawing on reverse side. <br /> Signed 117 �/� - <br /> Title: Date <br /> FOR DEPARTMENT SE ONLY <br /> Application Accepted by Data <br /> Area <br /> FjiPit or Grout Inspection by - Date' <br /> -�_ Final Inspection b ��� Date <br /> Addhional Comments. <br /> - <br /> y Applicant - Beturn all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services �-`�e. 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DIE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> ;1i 17.21 IREV.I/@15) <br /> 141a - V <br />