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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION d4.„ <br /> 445 N SAN JOAQUIN, PHONE (209)458 -3420tIL�_, . ,,F <br /> P O BOX 2009, STOCKTON, CA 952010 <br /> t <br /> PERMIT EXPIRES I YFM FBQM DTE ISSUED <br /> (Complete in Triplicate) <br /> 1 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 1962 and the Rules and Regulations of San <br /> f Joaquin County Public Health Services. <br /> Job Address fDL City Lot Size/Acreage �' �j� <br /> Owner's Name <br /> >�� 1 .f Address Phone <br /> Contractor nkiiC*,_3 50 Cticense No.L m�Phone <br /> TYPE Of WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION.0 ' SYSTEM REPAIR ❑ OTHER Cf Monitoring Well ❑ <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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ir 1 <br /> n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other (l Delta Depth of Grout Seal Type of Grout <br /> 'I 1 lrrigatian Approxi Oepth,x l I Eastern Surface Seal Installed by <br /> Repair Work Done 1,U Type of Pump H.P. l .w State Work Done _ <br /> Wall Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth "Filler Material,& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1tf1 !REPAIR/ADDITION I DES TION lNo septic system permitted if public sewer is <br /> : available within 200 feet. <br /> f Installation will serve: R 'idenr e'_!:�C�mmercwl Other <br /> Number of living units: , Number-of,- Vs� <br /> Character of too to a depth of-1 feet: Water table depth <br /> �. SEPTIC TANK. fiYTypsiMfg ► - R Capacity No. Compartments ” <br /> PKG. TREATMENT PLT.© % `. 'Y Method of Disposal <br /> " OWance to nearest; Well �� Foundations Property Urne � <br /> LEACHING LINE yt�a Lengtti of linesr Tota�;Ienglh/site r + <br /> FILTER BED ❑ Distance to nearest: 'Wall• Property Line p� <br /> l Y_14 ' <br /> f r <br /> SEEPAGE: PITS 1 4�th Site Number '. x <br /> SUMPS Ll Distance to ' rest:, Well _.Foyndation _Property-Lino w <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this a lication and that the work will be done in accordance with an Joaquin county ordinances, stata-", and <br /> rules and regulations of the San Joaquin County l-. r <br /> Homs 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 of 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 compenss- <br /> 4 tion laws of California." <br /> ,The t must c all requir ape ns 1818 drawing weverse s. <br /> Sig Tit , tJI'�7L1��/laF.sem t Dater <br /> 1 FO EPARTMENT USE ONLY- { <br /> I <br /> Application Accepted byC�■w ! at,, . __ Data Area t <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by, Date <br /> ddillonal Comment$: <br /> ` Applicant - Return all copies to: San Joaquin C ty Health Services <br /> Environmental Health Permit/Services t <br /> - 445-N-Ban_Joaquin.,...,P_O..Box_2009.,..Stkn.,.rCA-95201 . <br /> f <br /> FEE AMOUNT DUE AMOUNT REMITTEO CK# RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH EH 13.24(REV.t/it 5 113 <br /> EH 14-M l <br />