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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR-FROM DATE_ I„$SUED <br /> (Complete in Triplicate) <br /> Application i■ hereby made to Baa Joaquin County for a permit to construct and/or install the cork herein described. This <br /> application is made in compliance vi.th San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Pub�cfirth Services. <br /> {�S r <br /> Job Address &A19Q City Lot Size/Acreage <br /> /J/f <br /> Owner's Name Address /�l e>do LR _ Phone <br /> Contractor tAddress����4�/I�fsst Lice No.+� L Phot+ <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLAT19N ❑ SYSTE REPAIR ❑ OTHER p Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ,QCL!,-Ec SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION �A- ° — AGRICULTURE WELL gQ' ~OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X� <br /> Cl Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ 17;VL s Specifications "� <br /> I'1 Public ri Othef 1-1 Delta Depth of Grout Seal 1t 91 Grout C� <br /> >luigation / /',^jpprox. Depth I I Eastern Surface Seal Installed by �/d fs L>vi In <br /> Repair Work Done L] Type of Pump N.P. State Work Done <br /> Well Destruction 0 Welt Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 feel.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of sag to a depth of 3 fast: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ C3 <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 /> rubs 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 $hall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California,- Contractors 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 ehali employ persons subject to workman's compensa <br /> tion laws of California.” <br /> The applicant must call for <br /> all required ins ctions. Complete drawing on reverse side. <br /> Ki � c' Title: `u silol Date: <br /> �-Er_ARTMENT USE ONLY <br /> Application Accepted by � 1v alb Date L Area 12 2-.- C <br /> Pk or Grout Inspection by Date Final Inspection by Date <br /> � r <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P x 2005, Stkn, CA 95291 <br /> `IFEE AMOUNT E AMOUNT R ITTED CASH ECEIVED BY D E PERMITNO. <br /> EH 13-24INOV.r/A5) <br /> EN 11.26 <br />