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APPI,I CATI ON,FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC-HEALTH SERVICES <br /> ENVIRONMENTAL HEALTHDIVISION <br /> 445 N SAN JOAQUIN, PHONE (209-468-3420 <br /> P O BOX 2009, . STOCKTON, CA 95201. <br /> j�. <br /> PERMIT EXPIRES l Y FR M D T SII <br /> ((;omplete 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 easrpliance with San Joaquin County Ordinance No. 549 and 1882 and the Rules and Regulations_' Ban <br /> Joaquin County Public Health Services. <br /> c� �l <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Jnhin Address C L_ I__969- l Phone 9'3S - 4100 <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <br /> WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring hell ❑ t <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 /> ❑ Industrial 0 Open Bottom IT-Manteca Dia. of Weil Excavationk <br /> Dia. of W I Casing <br /> f7 Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing 5pe�fications <br /> Il Public. f"1 Other n Delta Depth of Grout Seat <br /> I I Irrigation A Type of Grout <br /> .� pprox, Depth I I Eastern Surface Seal Installed by f <br /> Repair Work Done U Type of Pump H.P. Stats Work Done <br /> Well Deiitruct'an O Well Diameter Sealing Material & Depth f <br /> Depth tiller Material i Depth T <br /> TYPE OF_SEPTIC WORK: NEW INSTALLATION P4, REPAIR/ADDITION I I DESTRUCTION I I (No"septic system permitted if public sewer is <br /> nce - j vaiiable within 200 feat.l <br /> Installafion wilt serve: Rsieence� Commercial rOther j <br /> Number of living units; _.Numlier of'badrloms- / V) <br /> Character of 604-to i nth of-34"t— <br /> SEPTIC <br /> f-3feltsSEPTIC TANK. 11 ,Typal/Mfe ! , _,,t :- Water table depth d <br /> Capacity No. Compartments 2- } <br /> PKG. TREATMENT PLT.it <br /> `�. —CO , fi Method of Disposal <br /> Distance to-nearest; WeN. Foundation__A___"� Property Line <br /> LEACHING LINE Ix Na. 6 Leng1.th of linea =. D O = Tgtal length/size O O <br /> FILTER.BED ,__p��Distanee to nearest:. i well -" 00 /Foundation <br /> --J-ACL�_ Property Line ` <br /> - <br /> SEEPAf3E PETS I I Depth Siie Number <br /> SUMPS Cl .-Distance_to4nsamt: -Well- FoundationPro <br /> DISPOSAL PONDS p Property Lina <br /> I hereby certify that I have-prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County F <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 /> certifies the fallowing: "I certify that in the performance of the work for which this permit is issued,I shall employ persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m t Call l required impactions. Complete drawing on reverse side. <br /> ii <br /> Signed'. Titled MData.' �• . <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by I - }� 1 <br /> Date Area 1 Q <br /> Pit or Grout Inspection by Date <br /> — Final Inspection by Date <br /> . � <br /> �.. <br /> Additional Comments: <br /> J. <br /> -.._ Applicant_-_Se.turn_al]...cop,ies- t-O:•-.rSa-n-Joaqu-in-County Pubile-Health Services <br /> Environmental Health Permit/Services <br /> 4 445,N San Joaquin, P O Box 2009, Stkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCX <br /> ��� <br /> INFO T <br /> CASH RECEIVED BY DATE° PERMIT'NO. <br />. EM 13•M tItEV.tr651 14 <br /> V <br /> EN 14.76 <br /> } <br />