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APPLICATION FOR PERMIT <br /> SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN* PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> e44 <br /> j <br /> PERMIT EXPIRES 1 YEAR FROM DATE_ ISSUED <br /> ! (Complete in Triplicate) >) 2 <br /> C <br /> Application is hereby made to San Joaquin County for- a permit to construct and/or inatall the work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. „ <br /> Job Address - ' City Lot Size/Acreage <br /> i <br /> Owner's Name ` } Address 7. ` /%' `�G�✓1 Phone <br /> Contractor dress 1703 <br /> `f License No. J Phone ` / �� 2 <br /> TYPE OF WELL/PUMP: V NEW WELL ❑ WELL RE LA ENT El -DESTRUCTION ❑ Out of Service Well I! <br /> PUMP INSTALLATION ❑ SYSTEM R PAIR-Cl.a OTHER 0 Monitoring Well ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK., SEWER LINES POSAL FLD. PROP. LINE j <br /> FOUNDATION f r AGRICULTURE WELL--. --- —f-OTHER-WELL PITS/SUMPS F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS ION SPECIFICATIONS <br /> C1 industrial ❑ Open Bottom € © Manteca D' . 0 W Excavation Dia. of Well Casing <br /> C7 Domestic/Private ❑ Gravel Pack_,J b'Tracy Type of C sing_ Specifications <br /> I'I Public Cl Other k --n Delta Depth of rout Seal Type of Grout / <br /> I I Irrigation ___Approx. Depth I 1 faster , Surface eai Installed by <br /> Repair Work Done O Type of Pump = ' ' H.P. State Work Done <br /> Well Destruction 0 Well Diameter ' Sealing Material lr Depth <br /> Depth Piller Material 4-Depth r� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ! REPAIRlADDITION f I ' DESTRUCTION f I !No septic system permitted if public sewer is <br /> avails le Withilif 200 feat.! n <br /> Installation will serve: Residence_ Commercial ther <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Typo/Mfg ._- Capacity U U No. Compartments <br /> PKG. TREATMENT PLT.0 - Method of Disposal <br /> IN to nearest: Well_1UFoundation_ Proper R ine <br /> LEACHING LINE. Cl No. b LengthLof linea 1/ of length/size <br /> FILTER SED 0 Distancito nearest. Wall oundation 2_ Property Line <br /> F <br /> SEEPAGE PITS 11 . Depth J 1M Size Nu ►. - <br /> SUMPS Cl Distance to est: Well U oundation roperty Line <br /> DISPOSAL PONDS © �i <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state lawns, 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 any person in such manner as to becor4subject to workman's compensation lawns of California."Contractor's hiring or 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 compensa- <br /> tion laws of California." +. <br /> The applicanly1pust call for uired inspection. Complete drawing on reverse side. <br /> Signed X V11wr < Title: i Date: 12 1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Q, (ZES Date. `' Area <br /> Pit or Grout Inspection by Date Final Inspection by# //[�� Date <br /> Additional Comments: t <br /> . r � <br /> Applicant - Return all copies+to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE j AMOUNT REMITTED KlWi ECEIVED BY DA PERMIT*NO. <br /> . EM 13. (REV.i i n s) , J <br /> /f r <br />.. _EM.14.2ax � <br />