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APPLICATION FOR PERMIT <br /> k SAN 4OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPI _ 1YEAR kROM, DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork 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. _� l <br /> Job Address 53}F' aC �-✓Y _ City Lot Site/Acreage <br /> Owner's Name z� '� Address _ !LS%TT//fT Phone <br /> Contractor r/ S ddress c:2f�� 64f2-1;=License No. t / Phone <br /> . f1j{,. <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT (-} DESTRUCTION ❑ Out of Service well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHE j. Monitoring Nal [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial Cl Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ADomestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> ❑ Public l:7 Other [ ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation _A p-prox'. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth } Filler Material 4 Depth <br /> r TYPE Of SEPTIC WORK: NEWINSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet) <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 feet: Water table depth +� <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> � CLQ <br /> e LEACHING LINE Cl No. & Length of lines Total length/size S <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line ~ <br /> i 1 � <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance io nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 a <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 ofthe 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 shell not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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 Iowa of California," ;.� <br /> The applicant t r equi c ' Coniplels drawing on rover <br /> Signed Title: Date: <br /> 2=Z <br /> EFA-RTMENT USE ONLY <br /> Application Accepted by Date 2- Area q <br /> Pit or Grout Inspection by C I Date Final Inspection by Data <br /> m $ L <br /> Additional Coments: ✓t.at 0 tc C d 1! u,6� __ <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . <br /> ENVIRONMENTAL-HEALTH DIVISION PERMIT/SERVICES <br /> 446 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE , AMOUNT REMITTED CK If <br /> ASH RECEIVED By DACE PERMIT'NO. <br /> JH+ EM1` IREY.1iM51 O �111 � , r 't1 l �I� 7L/ gDTd�7Z dA <br />