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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Dam <br /> ENVIRONMENTAL HEALTH DIVISION, C V <br /> n <br /> P O BOX 2009 STOCKTON CA 95201 <br /> (209) 468-3447 MAY 2 8 1991 <br /> EMIT EgPIEtES 1 YEAR rftom DATE IssuEENVIRONMENTAL HEALTH <br /> (complete in Triplicate) PERMIT/SERVf�� <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein descri e S This <br /> application is made in campliaace with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �} t <br /> Job Address `3 • City Lot Size/Acreage <br /> Owner's Name �f ✓��; - Address Phone <br /> C <br /> Contfacto��t-�� Address O `6 15�� Oiicense N 9?1 Phone �=D$/ <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR &0� OTHER p Monitoring Kell` C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_,., PITS/SUMPS � w. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n In O Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> Domestic/Private O Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout CP <br /> IZI Irrigation Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 116 Type of Pump ,4 H.P. i;1 -- State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth LP <br /> Depth Filler Material i Depth <br /> TYPE, Of SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION CT DESTRUCTION 1=1 1No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence^ Commercial.-,_. Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity l No. Compartments , <br /> PKG. TREATMENT PLT, 0 4 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> 00 <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Li Distance to nearest: Well Foundation Property Line ' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wi$l 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 (amity 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 workmen'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 /> tion laws of California." <br /> The applicant must I for all requ inspections. Complete drawing on reverse side. p <br /> Signed Title:A—eA_ --- _ Date: �_1?_0! <br /> t <br /> ��� OR DEPARTMENT USE ONLY �f <br /> Application Accepted by Data F7 tw Area <br /> Pit or Grout Inspection by Date Final inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT OVE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0, <br /> + <br /> 6H 13•26(REV.7�R51 �� <br /> E14 A-36 <br />