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'f <br /> r APPLICATION FOR PERMIT <br /> I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION nJo <br /> 1445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> i P O BOX 2009, STOCKTON, CA 95201 <br /> 'PERMIT EXPIRES I YEAR FROM DATE SU <br /> (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 /> t i Josquin;County Public Health Services. <br /> r <br /> tk Job Address rte' 5� City !E:Z-W1 _- Lot Sire/Acreage <br /> .....y". _ ! - Address Phan <br /> I <br /> Owner's Name F Y <br /> i.w pf t fi S <br /> /Y W.. � O <br /> Contractor Addres- r License N�!J Phan <br /> TYPE,OF{WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n 'DESTRUCTION­0 Out-of Serviee-well9 0 <br /> s PUMP INSTALLATION CL-, __4 _SYSTEM AEP�IR_❑ OTHER ❑ Monitoring Well <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE;OF WEtL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> r - <br /> El l Domestic/Private . ❑ Gravel Pack Cl Tracy r 1 6. ds Tape of Casing_ Specifications <br /> ['I-Public El Other f1 Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation " f �Approx. Depth I�I Eastern Surface Seal Installed by <br /> Repair Work Done 0, Type of 4Pump H.P. 1 State Work Done <br /> Well-Destruction "r"❑ `Well t?iamotor Sealing Material & Depth. <br /> r �'' Depih Mller Material 4 Depth f <br /> ft ------- - ^ <br /> PYPf OF SEPTIC WORK; NEW INSTALLATION I k REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is 4\ <br /> ' r <br /> serveA available within 200 feet.) <br /> Installation will : Residence�r Commercial�.: __ Other A` <br /> N.mbw of living units: pNumber of bedrooms 7ANK— C " <br /> Choractar of soli to a depth of 3 feet:j Water table depth <br /> SEPTIC TANK. Type'/Mfg - Capacity No. Compartments <r t <br /> PKG. TREATMENT PLT.❑ Yt w w Method of Disposal <br /> 4 �•. :�.-., - Distance to nearest: Well - .Foundation.- Property Line <br /> I LEACHING LINE ❑ No. S Length of lines Total length/size <br /> t <br /> FILTER BED C1Distiyynce to nearest: Well Foundation Property Line ; <br /> 4SEEPAGE PITS I ) Depth t ' Size J Number <br /> SUMPS I L1 Distance to nearest: Well Foundation Property Line <br /> 'DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 /> ceriifiss the following: '9 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workrnan's compensa- <br /> tion tam of California." x <br /> The•applicant irxi - I r required ins ion Camplet drawing on rev Beside. <br /> Signed i� Title: Date:7= <br /> EPARTMENT USE ONLY <br /> lC ; <br /> Application _• <br /> Accepted by . _ ` y Date ` Area <br /> Pit or Grout Inspection by Date Final Inspection byr,CL„ -- �^ Date <br /> Additional#Comments: <br /> t <br /> Applicant •- Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 495 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> - � INFO <br /> . EH 13-24 iREV,t s) rid Z?� , �7/ <br /> EH 14.2 <br />