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' APPLICATION FOR PERMIT <br /> ,._._- .SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �r <br /> ENVIRONMENTAL HEALTH DIVISION � "` <br /> P O BOX 2009, STOCKTON, CA 95201 3 , <br /> (209) 468-3447 f <br /> 4 f SEP 2 fx <br /> EgMIT IRIS MDT <br /> 1 YEAR PR4ATr. L = ' <br /> E.a (Complete in Triplicate) ENVIRONMENTAL h'EAL_ 1___ <br /> Application is hereby made,to Sao Joaquin County for a permit to construct and/or install the wo er izi,, scillbd: -ryThis <br /> application Is made in ceetplianco.vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regul.ati6its' -San <br /> Joaquin County Public Health Service/s. 4 % ; <br /> Job Address Lot Site/Acreage <br /> } I <br /> f <br /> �Owner's Nemo r Address Phone <br /> e No. Phone � f <br />' • ontr or - dOT�' <br /> TYPE OF WELL/PUMP: NEW WELL Q 0. <br /> WELL REPLACENI T ❑ DESTRUCTION ❑ Out of Service well <br /> +� SYSTEM REPAIR LI OTHER ❑ Monitors 1ie11 <br /> Ll <br /> PUMP INSTALLATION 1� �� e <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom E) Manteca �. Dia. of Well Excavation Dia. of Well Casing <br /> a Specifications <br /> /P_rivate__�� <br /> C] Gravel Pack ❑ Tracy Ype'of Casing_ _ „ . , ____. __„ �__ <br />'I Q Atlblie ("I Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Gi Irfipatian _.Approx. 09th �� Eastern Surface Seal Installed by <br /> Repair Work Done U Tyne of Pump / H•P• .— State Work Done _ r <br /> Well pastruction ❑ Well Diameter - <br /> Sealing Material 4 Depth `�Y <br /> Depth �:5�7 ruler Material i Depth <br />.k TYPE Of SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION Ll DESTRUCTION.CI INo septic system permitted if public sewer is <br /> available within 200 feet.I <br /> installation will serve: Residence— Commercial— Other <br /> i Number of living units: 'Number of bedrooms <br /> Character of soil to.a depth of 3,fee1:_ t Water table depth <br /> SEPTiC•TANK ❑,e Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT-PCT'Cl"”—''s`"+a� Method of Disposal <br /> Distance to neares.�t: W II Foundation Prope ly Line <br /> LEACHING LINE Cl fva. a Length of lines Total length/size Q <br /> FILTER BED ❑ ,Cisiance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number' - <br /> s SUMPS LI Distance to nearest: Well Foundation Property Line _ <br /> v prepared this application and that the work will be done in accordance with San Joaquin DISPOSAL_PONDS�,� <br /> I hereby certify that I have p ep pp n county ordinances, state laws, and <br /> F 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 of subcontracting 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 compansa• '�- <br /> tion laws of California." it <br /> The apptican[ tail f all squired insPections. Complete drawing on rev rag sid ' F <br /> Signs /�It� Title: Dater <br /> r FOR DEPARTMENT USE ONLY f� <br /> / 6_D Area_�� <br /> Application Accepted by Date . P <br /> Pit or Grout Inspection by Date Final Inspection byD aQ <br /> Additional Comments: ' <br /> ,.t <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `( <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES CCtVj ' <br /> 445 N SAN JOAQUIN, P 0 BOR 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE 6 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> INFO <br /> EH 17-24IREV,I I M 5 1 J ` O o... 17/Z5 <br /> EN ! , <br /> ` Q <br />