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* APPLICATfON `FOR PERMIT <br /> - A . <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 /> cPERMIT 'ESPIRES -1 YEAR-FROM 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 is campiiancelvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ! <br /> Job Address lt; City Lot Size/Acreage <br /> is Ns <br /> Address Phone <br /> �p� � rte, Q J Q 71 <br /> # <br /> C r ' fllM�Address ems« L c Flo. Y�� O ` Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ..�/' DESTRUCTION 0 Out of:ServiceWell Q <br /> PUMP INSTALLATION D SYSTEM REPATII+Iv� OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - - <br /> F C1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> alit/Private C1 Gravel Pack 0 Tracy Type of Casing Specifications r,7 <br /> 1 Public n Other 1 I (� Delta Depth of Grout Seal Type of rout I <br /> i I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by ' r <br /> Repair Work Done D Type of Pump H.P. State Work D i <br /> Well Destruction D Well Diameter Sealing Material i Depth <br /> f Depth i Filler Material i Depth .' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.} { <br /> Installation will serve: Residence{Commercial ___Other ; 11 <br /> Number of living units: Number of bedrooms - <br /> Character of soll to a depth of Vast-,► b - -- ?� Water table depth <br /> SEPTIC TANK ❑ Typa/Mig I Capacity No. Compsrttnanta <br /> PKG.'TREATMENT PLT.Cl 4 t""� `"""Mathotl of Di>spof I'* <br /> Distance to nearest: Well Foundation. i Property Lin,-- <br /> LEACHING <br /> ine=LEACHING LINE 0 No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation ; - _Property-Line. I <br /> I M <br /> i SEEPAGE PITSI I1(Depth ' Size Number. <br /> BUMPS. , ° x�Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r r <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 /> 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 tiny person in suet manner as to become subject to workman's compensation laws of Caiifornia."Contractor's hiring or subcontracting signature <br /> certifies the fopowing: ' csrtify at in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws o ia.11 , <br /> The applic E tell for fired ' pec ions. om late drawing on rev side. 1. <br /> 4 Sig Title' Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ - - T.___—_ Dale ea L <br /> Pit or Grout Inspection by Date Final Inspection by Dats <br /> A�j3 <br /> Additional Comments: ' <br /> Applicant - Return all copies to: San Joaquin County Public Health Services i <br /> 1! Environmental Health Permit/Services <br /> 445 H San Joaquin, P 0 Box 2009, Stkn, CA 85201 <br /> . FEE AMOUNT DUE AM N,T REMITTED d[�7K�Z, RECEIVED BY , TE Py <br /> ERM�IT'' <br /> NO. <br /> INFO CASH <br /> EH 13-24(REV.1/R6) 11 9- <br /> EH 14.0 <br />