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APPLICATION FOR PERMIT <br /> I� SAN JOAQUIN COUN -PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN .IOAQUIN,- PHONE (209)468-3420 <br /> c P O BOX 2009, STOCKTON, CA 95201 <br /> ' PERMIT .EXPIRES I 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 vork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 18¢2 and the Rules and Regulations of San <br /> Joaquin CouAy Public Health Services. � <br /> Job Address /W, -l 1 r /1 L it Lot Size/Acreage <br /> n 's Na,60fi"Zww-�g.ddress �w + 2LIarclmPhone 6 <br /> aor [` fess 4fF,honeJ�L-q- <br /> TYPE OF WELL/PUMP: NEW WELL�_El/' � WELL REPLACEMEN n DESTRUCTION ❑ Out of Service Well ❑ <br /> 11� PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ ;14onitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK [ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ;I1. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E7 I (ustrial �` LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> o alit/Priovate Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 3 Public �� fl Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation it, _Approx. Dept - I I Es rn Surface Seal Installed by <br /> Repair Work Done U Type of Pumo `•-- H. Stato Work <br /> Well Destruct) 0 Well Dia et�`/ r Sealing Material & Depth <br /> Depth !'filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/AODITION I I DESTRUCTION I 1 1No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residenca_L�;, Commercial— Other } <br /> Number of living tincts �N tuber of bedrooms <br /> Character of soli to a depth,of 3 feet: Water table depth <br /> SEPTIC TANK.�[ Y 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT.PLT.,C] Method of Disposal <br /> Distance to nearest; Welles Foundation Property Line <br /> LEACHING LINE J❑ No. &,Length of tines Total length/size <br /> FILTER BED. ❑f bistanc.to'.nearest: Welly Foundation Property Line <br /> y <br /> I SEEPAGE PITS l j%--Depth " Size Number _ <br /> SUMPS i LI Diste'r►cs`to clearest: Well Foundation Property Lina <br /> I DISPOSAL PONDS. ❑ 1 v <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 /> 1 rules and regulations of the San Josquir County <br /> Home owner or licensed agent's tignatuie 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_mannars to become subject to workmen's compensation laws'of-_California." C_otractor�s_hiririg oLsub 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 all , <br /> i The apptica °s call for Ir in ions. Complete drawing on erre <br /> Date: <br /> ` t _ FOR DEPARTMENT USE ONLY <br /> Applicatlon Acce`ptad-bye � Date Aran <br /> Cl <br /> Pit or Grout l nsA � y � <br /> pection by Date Final Inspection by C- Date <br /> i, <br /> Additional Comments: t <br /> i <br /> I Applicant - Return all copies to: San Joaquin County Public Health Services <br /> I Environmental Head erm t/S 'vices <br /> 445 N San Joaqu , P O " Stkn, CA 95201 <br /> i INF AMOUNT DUE AMO T REMITTED CK ECEIYED BY DOE PERMIT'NO. <br /> • EH 13-241REV.r/tiSl rVY <br /> EH 14•�s • (tel/J[� a <br /> 1 'M <br />