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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 /> PERMIT R IREg I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i Application Is hereby made.to San Joaquin County for a permit to construct rind/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 /> Job Address1141 City { Lot Size/Acreage//� J <br /> t <br /> Owner's Name Address <br /> � J_--1111 <br /> _ rr�� �—,....,.._� Phone <br /> Contractor f� l Address ( AJ-�1y1J <br /> icense No. Phone Z �� <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ 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 /> D Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I 1 Public n Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> r <br /> Repair Work Done Ll Type of Pump H.P. State Work Done <br /> WON Destruction ❑ Well Diameter Sealing Material A-Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feel.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms (P <br /> Character of 80N to a depth of 3 feet: Water table depth O <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No, b Length of linea Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 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 will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Horne 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 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 tows of Cali nla." <br /> The call f all requir i , tions. Complete drawing on reverse side. Q i <br /> ned Title: Date: r s-- <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted bya.0,4 Q l <br /> Data r Area <br /> Pit or Grout inspection by Date Final Inspection b Dat <br /> Additional Comments. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DtJE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> . tM t}z,IREV.„rsI <br /> EM N-Ta <br />