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x APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (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 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 /> Job Address .2�]VS23 �Zz/+ 2«f City �n_/"�+�� Lot Size/Acreage �Q <br /> Owner's Name /�i�!'6/ydCG \�Y•���1 Address Phone <br /> Contractor !� Address S % '/ License N � Phone <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT P DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION C SYSTEM REPAIR O OTHER Q Monitoring Well Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial O Open Bottom I� Manteca Dia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Private Q Gravel Pack O Tracy Type of Casing___-__ Specifications <br /> I'1 Public f_] Other i fl Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation —Approx. Depth 11 Eastern Surface Seui Installed by r <br /> Repair Work Done U Type of Pump H.P. State Work Done _ U <br /> Well Destruction O Well Diameter } Sealing Material i Depth (� <br /> Depth ]Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I .DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence — Commercial /Other'..'i,d1) ? '�C� <br /> Number of living units: Number of bedrooms - <br /> Character of sou to a depth of 3 feet ' _L - Water table depth <br /> n, <br /> SEPTIC TANK e— Typo/Mfg C p'�[ — 0 V6� Capacity 00 No. Compartments <br /> PKG, TREATMENT PLT. 0 '1 Method of Disposal <br /> Distance to nearest: Well Foundation _ _ L�_ Property Line <br /> L4 <br /> LEACHING LINE [X No. 6 Length of linesr Total length/size <br /> FILTER BED P4-- Distance tonearest Well 70 Foundation � Properly Line <br /> SEEPAGE PITS W--Depth a2�i_ / t Size " Number <br /> SUMPS LI Distanceto nearest: Well 7 Q Foundation / <br /> Property Line l <br /> DISPOSAL PONDS ❑ r{ <br /> ~ :'1 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 San Joaquin County " <br /> Horns owner or licensed agent's signature oerfifkn the following: !'I comity that in the'performance of the work for which this permit is issued, I shell 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 thiel permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." 1! <br /> The applies call or fsll'r uir tnapsctions. Complete drawing on reverse side. <br /> t _ <br /> Signed X Title: I Date: �/y <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 'F3 Area <br /> s Pit or Grout Inspection by gate fin 1 Inspection;Py Dae q 2D <br /> Additional Comments: <br /> Applicant - Return all copies io: 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 REMtTTED ECEIVE BY O TE PERMIT'NO. <br /> INFO i! ER �} <br /> EN 13-2{INEY.1/x51 N // f, d� �/ O/ ✓9zn ` ✓ —// <br /> fie 14-20 /� __ •"Y/ !/ <br />