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APPLICATION FOR PER9I7 _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE?-- <br /> ENVIRONMENTAL HEALTH D I V I S 010i # <br /> 445 N SAN JOAQUIN, PHONE (209) CR4#0 <br /> I ) V0P O BOX 2009, STOCKTON, CA <br /> PERMIT EXPIRES 1 YEAR FROM DA EF <br /> (Complete in Triplicat )1 `, r <br /> Application is hereby made to San Joaquin County for a permit to construct and tt �/ he ein described. Th s <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and ions of San <br /> Joaquin County Public�lHealth Services. rr� <br /> Job Address / 7 6 A 9, W' /c/tyovel "' City �rCpy�O� Lot Size/Acreage <br /> Owner's Name `' &ON19i `d VIPQ yrs Address S,4M� Phone <br /> Contractor J A Address 600,7 6 �� /f90o1NJ�D License No. ��$$0 f/, l Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications <br /> I"1 Public Cl Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ n <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC VYORK: NEW INSTALLATION I I REPAIR/ADDITION XI DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will wive: Residence Commercial_ Other <br /> Number of Irving units: I Number of bedrooms d <br /> Character of soil to a depth of 3 feet: <1Y Water table depth too <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal IN <br /> Distance to nearest: Well Foundation Property Line (i <br /> n, <br /> LEACHING LINE No. b Length of lines y0 Total length/size t ,� <br /> FILTER BED ❑ Distance to nearest: Well ISO' Foundation %� Property Line <br /> I . <br /> SEEPAGE PITS k1 Depth ' Size.. 36 �'y Number t <br /> SUMPS LI Distance to nearest: Well 00` 'Foundation Property Line <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 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 /> employ 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 followingQ "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 Califorrmta.11 <br /> The applicant m st call for all required inspections. Complete drawing on reverse side. <br /> Signed '�� 7� Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C Date Area z- <br /> tAdi <br /> ZI <br /> ut Inspection by Date Final Inspection by Date Comments: <br /> Applicant - Return all copies to: 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 <br /> NFO AMOUNT DUE AMOUNT RE ITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-211REV.rinsr OA <br /> EH 162e <br />