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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 EXPIRES I YEAR FRQM D TE S <br /> I (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. 51+9 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health 9ervicea. t <br /> City Lot Size/Acreage <br /> Job Address � <br /> {Il!r, 'BO 1 <br /> } Ph�no <br /> Owner's NameAddress . <br /> Contractor F r1 Address ` <br /> �V� "�Q- License Nt>= 313-1 Phone � 2-1 <br /> TYPE OF WELL/PUMP: IYEW WELL Cl WELL REPLACEMENT DESTRUCTIONOut of <br /> LLService Well 0 <br /> PUMP INSTALLATION (31 <br /> ti SYSTEM 'REPAIR OTHER Monitorinf Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK! ----SEWER LINES "� DISPOSAL FLD. • PROP. LINE i <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITSISUMPS o ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> C] Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 5peciticationa <br /> Il Public C1 Other " fl Delta Depth of Grout Seal Type Pf Grout <br /> �t✓n r. <br /> UJ <br /> I I Irrigation r �.Agprox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U ' Type of Pump i. � H,P. j tate Wafk Done <br /> Sealing Material i Depth V +"V'e, <br /> Well Destruction ❑ Well DS <br /> iamster`�-- <br /> Depth r Tiller Material i Depth i� ► �J- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> s available within 200 lest.) <br /> s <br /> Installation will serve: Residence Commercial_ Other <br /> �. <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water tabic depth <br /> SEPTIC TANK. ❑ Tyl r/Mfg i ;' Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 ' y Method of Disposal � <br /> Diatanca It Well Foundation Property Lina <br /> LEACHING LINE n No. 5 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest Well FoundationProperty Line <br /> 1 <br /> SEEPAGE PITS .1 1 Depth Et Size Number <br /> SUMPS Ll. Distance toynearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 v <br /> rules and regulations of the San Joaquin County ! <br /> Home owner or licensed agent's signature certifies the following:."I certify that in the pefforniance 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 signeture � <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 workmen's compensa- <br /> tion lays of California." <br /> I <br /> The applicsfU must tail for�Wv'rinspectibns. Complete drawing on reverse side. <br /> Sigfed Title: bL-10-5 Data: Q� <br /> f ENT USE ONLY <br /> � - <br /> APP Accepted <br /> Application Ace ted by 1 Date <br /> PK Grout I by ate 3 Final Inspection by ata <br /> Additional Comments. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services Old, <br /> 'Pexmit%Services <br /> gQ / 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATS PERMITNO. <br /> NFO <br /> EM*24 IItEV.1/n Ila � � �� 1 °l� � �.� �✓1� / ,3 3 <br /> EN 1626 P <br /> 7 <br />