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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P .0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a per=it 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 /> Jab Address _ / "�4, '�'� ��''f`- - Cit Lot Size/Acreage <br /> Owner's Na a Address � �"�`J Phone <br /> ContraAddre�� __.�d `S3� License PhonE � <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT C] DESTRUCTION Ll Out of Service Well 0 <br /> PUMP INSTALLATION ❑ ,SYSTFI_A-RgpA,, R� OTHER ❑ Monitoring Well C7 <br /> OISTAf CE TO NEAREST:,SEPTIC TANK SEWER LINES ��^ DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial O Open Bottom ❑ Manteca Dia, of Well Excavation Dia. IP- AV <br /> EJ DomesticIPrivait Cl Gravel Pack 111 Tracy Type of Casing Specificatiod Puglic i l Olhar ❑ Delta Depth of Grout Seal Type of Gro <br /> CJ Irripalion Approa. Depth ❑ Eastern Surface Seal installed by f ' <br /> Repair Work Done jjpe e-of-Pi,mp:%1=t . = H.P.�� State Work Dona te <br /> Well Destruction O Well Diameter Sealing Material i Depth (� <br /> Depth Filler Material i Depth- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION 0 . DESTRUCTION CJ (No septic system permitted if public sewer is <br /> available within 200 feet.) r� <br /> Installation will serve: Residence_, Commercial_ Other `�1 <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0. Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O �`itAA G , <br /> i sal <br /> Distance to nearest: Welt Foundation PRE '! ,�2�� <br /> Q <br /> LEACHING LINE. L1 No. & Length of lines Total lerigtii%aiz <br /> FILTER BED ❑ Distance to nearest: Well FoundationSAf ,I ghQtjgjGu'tl�Ty <br /> � U LIC HEALTH SEIWICFS <br /> SEEPAGE PITS 11 Depth Size Num erMtll AL hi <br /> l 1 DIVISION <br /> SUMPS LI Distance to nearest: Well Foundation Property Line V) <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, state laws, and <br /> rules and regulations of the Sen Joaquin County' ti <br /> Home owner or licensed agent's signature certifies the following: "I ciMify 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 workmen'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 Iaws of Catifor <br /> s" The applicant m 4 o 11 required itis ctions. Complete drawing ort erse side. z <br /> Signed Title Date: r/ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date gMz Area tG <br /> Pit or Grout Inspection by Date Finan Inspection by Data <br /> Additional Comments: <br /> Applicant - Return a.11 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> INFO AMOUNT DUE AMOUNTT nE•MiTTTED SCK RECEIVED BY I DATE y PERMIT'NO, <br /> EN43.tb7e.74 IIIEV.I/�31 <br /> EN ,�(..�G�> / �G,. 2 F <br />