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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> L� P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I' YEAR FROM D TE 1§8UED <br /> its (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 miLde in cearpliance with San Joaquin County Ordinance Ro. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> CityL-4 �•S Lot Size/Acreage <br /> Jab Address <br /> of T i <br /> Ph <br /> f l0 Address one 'a_ jy <br /> Owner's Name , <br /> ,F <br /> Address License No3O'� 7� � <br /> Phone 3 <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL C3 vA <br /> . WELL REPLACEMENT ❑ DESTRUCTION ❑ Out lMfonitoring well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 /> a C1 Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fCl Domestic/Private ❑ Gravel Pack n Tracy -Type of Casing_ Specifications <br /> I'1 Public r CI Other n Delta Depth of Grout Seal Type of Grout <br /> lrril}ation r_ Approit.Depth I 1 Eastern 1Sgdi ca-Seal Installed by <br /> Repair Work Done U Type of Pump H.P. r State Work Dane <br /> t <br /> Sealing'Material i Depth <br /> WOR Destruction ❑ Well Diameter <br /> 4 Tiller Materiel ADepth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION i I DESTRUCTION-IJ--I No septic system availabe within 200 permitted if public sewer is (y` <br /> t. <br /> Anstallation wol.seive: Residence Commercial ! Other <br /> � Number of living unit: ___L Number o r ms <br /> Character of soil to a depth of 3 feet: - r Water table depth " } <br /> — .4 <br /> I •= SEPTIC TANK. L�;Type/Mfg.'S, p' Capacity No..Compartments l`C <br /> *- t <br /> PKG. TREATMENT PLT.❑ Method of Dispose! <br /> Distance to nearest: Well ;2� `. Foundation_ - Property Line <br /> &j / <br /> t; Z Tofallengthlsiie !.. <br /> r. LEACHING LINE L�No. b Length of lines <br /> FILTER BED ❑ Distancs'To nearest: Well�� Foundation O Property Line <br /> SEEPAGE PITS a 0---Depth _02*6 _Size �r Number <br /> ? SUMPS P L1 Distance to nearest: Well -230 Foundation ZVO-' Property Line_Z_Ifo ° _ <br /> DISPOSAL PONDS. ❑ <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 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant all for all req u ins tions. Complete drawing on reverse side. <br /> ,�c <br /> Signed Title: C[� ., Date. - — <br /> ja�- DREP-A-ATMENT USE ONLY <br /> Applicition Accepted by ��IsDate Area <br /> ix Grout Inspection by ate Final inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies-to! San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> xf 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY TE PERMIT'NO. <br /> INFO D/ <br /> . EK 13-21 IRtY.+iFtar <br /> EH t4.7a <br />