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F <br /> ` APPLICATION FOR PERMIT : <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESMAY 9 ��� <br /> ENVIRONMENTAL HEALTH DIVISION NIV1 z <br /> P O BOX 2009, STOCKTON, CA 95201 yl `'' " <br /> (209) 468-3447 �3E' tv3f SER ICES LTH <br /> pEg11IT EXPIRES--1 YEAR ?M DATE I.SSU <br /> (Complete in Triplicate) <br /> Application is hereby aiede;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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public H 4th Services. <br /> Job Address <br /> 1-1 City Lot Size/Acreage <br /> Phone <br /> Owner's Name Ad <br /> � �� -- <br /> • i � <br /> Contractor ____Address License No. �Z Phone <br /> TYPE OF WELL/PUMP: �I NEW WELL Cly ti.k,� WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well 0 <br /> + PUMP INSTALLATION 01L---� SYSTEM REPAIR ❑l-­� OTHER 0 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. PROP. LINE <br /> FO•LINDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> G n Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> � P <br /> 04 ffomesticlPrivate Cl Gravel Pack 0 Tracy Type of Casing Specifications .- - <br /> 13 Public (1Other 0 Delta Depth of Grout Seal Type of Grout p <br /> 0 Irrigation Approx• Depth 0 Eastern Surface Soul Installed by <br /> Repair Work Done Type of Pump H.P. _ 1`�"--Ql--- _ — State Work one <br /> Well Destruction O Weill Diameter Sealing Material 4 Depth <br /> IF <br /> Dei. Filler Material A Depth <br /> TYPE OF4SEPTIC WORK: NEW INSTALLATION 0 REPAIR IAODITION L7 DESTRUCTION 0 (No septic system permitted if public sower is <br /> IM . available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other 4 <br /> Number of living uniltl:t j• .Number of bedrooms t R <br /> . ---r.'.w._.� <br /> Character of tail to a depth,`f 3 feet: * ^-- - - �- __ _ Water table depth <br /> SEPTIC TANK ❑ r.Type/Mfg ° Capacity No. Compartments <br /> PKG. TREATMENT PLT, C1 I� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ..F <br /> LEACHING UNE Ll No. & Length of lines Total length/size <br /> i <br /> FILTER BED n Distance to nearest: Well.-- Foundation Property Line <br /> SEEPAGE PITS I I Depth' { �' Site Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 111, t <br /> I hereby certify that I have ri" are' 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 /> dome owner or licensed agent 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 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 /> lion laws of California." 11. <br /> TheaTitle: Date:pplicant must call f all.. in":clions. Complete drawing on reverse side. <br /> Signed ?(_ - _ __— -- - <br /> OR DEPARTMENT USE ONLY / <br /> F <br /> Application Accepted by Date �� Area <br /> Pit or Grout Inspection by Date Final inspection by ata ! <br /> ` Additional Comments: <br /> Applicant - Return all copies to: BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> : I ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> I, 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE I AMOUNT DUCE AMOUNT REMITTED RECEIVED BY DATE PERM17,NO. <br /> INFO � <br /> EH 13 24 IREV. 51 <br /> it - `101 S-1** <br /> EH,..zd pp <br /> R �� <br />