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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> r <br /> PERMIT EXPIRES 1 YEAR F&QM DATE 15SUM <br /> (Complete in Triplicate) <br /> Application is hereby made.to Sew 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 /> Joaquin County Public Health Services. <br /> `�, rA �' 1 , <br /> Job Address ✓ O " '� v City Got Size/Acreage <br /> A <br /> Owner's Name ! ,42 t� <br /> E�) --_ _ Address Phone <br /> � --- <br /> ( <br /> Contractor ,�� Address 3 Phone j.� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL:REPLACEMENT n DESTRUCTION Ll out or Service We ❑ <br /> PUMP INSTALLATION ❑ SYSTEM-REPAIR--❑,.�.,,., ,.,..,1... <br /> OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ; �Wt DISPOSAL FL'D. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- PITSlSUMPS �. <br /> INTENDED USE i'TYPE OF'WELL -PROBLEM AREA —CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private �Cl Gravel Pack [3Tracy Type of Casing= - %, Specifications <br /> j rou <br /> I'1 Public i f 1 Other n Delta Depth of Gt_Seal Type of Grout <br /> I I Irrigation Approx. Depth I 1 Eastern Surface Seal Instailed by a <br /> Repair Work Done 0 Type of Pump H.P. State Work Done-_ (�(. <br />` <br /> Well Destruction ❑• Well Diameter. Sealing Material A Depth W... <br /> ! biller "rial i Depth <br /> Depth th \ <br /> TYPE OF SEPTIC WORK: N W INSTALLATION PAIRlADDiTION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> F Installation will serve: Commercial= w , ther <br /> I Number of living units•. _�__ Number of bfooms�,` <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg &1 Capacity-,Z No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of,,Dispos} <br /> Distance to nearest: Well Foundation Property Lina!,.. % <br /> , <br /> LEACHING LINE t No. 5 Length of lines Totril <br /> length/size—Well Fouridation � Property Lina <br /> a <br /> l SEEPAGE PITS I I Depth r Size Number <br /> -umber <br /> f( SUMPS �eWance to nsarsst: Wtil Foundation�ti?C / Property Line <br /> DISPOSAL PONDS ❑ O <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 /> oe the foPlowing: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tio la Californcan .' <br /> The applicant t 11 for all r uir ins n C m to dr wing on t�t esid d <br /> Vi. ills: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by�T �- Y`�` i� -- Date F - Area <br /> Pk of Grout Inspection by - Date Final Inspection by } Data <br /> Additional Comments: -L Lei,r,*()r- oy 4J 16 S ,0 <br /> »TMApplicantA-Return-all-copies-to: -Sea:Joaquip County. Pub -fc°Hew1th-ServYeVr8— <br /> i Etivironmental' Health Permif/Services. <br /> 445 N San Joaquin," Box 2009, Stkn, CA 95201 <br /> FE AMOUNT DUE ; AMOUNT REMITTED CK H RECEIVED BY TE PERMITNO, <br /> 4/ fv♦ EH 13.24 INEV.I R w <br /> EH 14.25 r <br />