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r~ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL 4EALTH DIVISION <br /> 1601 E. HAZELTON AVEj ; PHONE (209)468-3420 <br /> P O BOX 2009-„- 8tOCKTON, CA 95201 <br /> EXP -RES 1 YEAR FR M DATE ISSUED <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 /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> Job Address ,., , <br /> i <br /> Owner's Name Address Phone <br /> F <br /> i ) <br /> l lContraclor L+._Z” Address License No. Phone <br /> f ` .TYPE OF WELL/PUMP: ✓NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCf T_0,NARESVSEPTIC­TANK`�" ""'SEWER-UlNES'' `DIS'POSA'L-fL"D;"�`' PROP. LINE <br /> ' FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> + i❑ Industrial f ❑ Open Bottom C] Manteca Dia. of Weil Excavation Dia. of Well Casing <br /> k [1 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> .I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> r sl I Irrigation Approx. Depth I i Eastern Surface Seal installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done_ <br /> -- -Sealing Material-� Depth--"^� <br /> 'Well Destruction. 1:1 Well Diameter .. <br /> Depth "Fille,'M&teri L 7.`Depth <br /> I'µp TYPE OF'SEPTIC WORK: NEW.INSTALLATION - REPAiR1ADDITION I I DESTRUCTION I I:INo septic system permitted if public sewer is <br /> available within 200 feet.M <br /> Installation will serve; Residence Commercial_ Other e <br /> I Number of living units: —"'Number of bedrooms __ <br /> Character of soil to a depth'of�3 feet: - - "" Water table depth <br /> ' SEPTIG TANK. ❑ Type/+Mfg Capacity ..� No. Compartments <br /> PKG. TREATMENT PLT. ❑ ?i <br />