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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 I <br /> PERMIT EXPIRES I YEAR FROM DATE ISSLIM <br /> ' = (Complete in Triplicate) <br /> rApplication is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is Made in coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules-and Regulations of San <br /> Joaquin County Public Health Se vic s. , <br /> 3 City Lot Size/Acreage <br /> Job Address ! 7, <br /> 020 <br /> Owner's Name r _lf l� - Address <br /> . , Z$ZZIP Phone X51-5105" <br /> Conhac w Address 1 +�, �� License No.- <br /> TYPE OF WELL/PUMP: NEW IJ 0 Ou <br /> t of Service Well <br /> WELL ❑ WELL REPLACEMENT ❑❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER El Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES-, �-� DISPOSAL FLD T ROP. LINE <br /> PTI T <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C09STRUCTION SPECIFICATIONS <br /> G Dia.'of`Well Excavation Dia. of Well Casing <br /> Cl Industrial ❑ Open Bottom ❑ Manteca <br /> r.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1 i ! Public !"1 Other n Delta Depth of Grout Seal Type of Grout <br /> a I i Irrigation x 4 —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type-of Pump_ HP. ° State Work Done <br /> r Sealing Nf ierial i Depth�. <br /> WellOestruction O� Well Diameter <br /> Depth Filler Material fr Depth <br /> 1 11 <br /> f TYPE OF SEPTIC WORK: NEW INSTAL TION^REPAIR/ADDITIOW� I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> t L Ovailable within 200 feet.) <br /> Installation will terra: Residents_.... Commercial_ Other <br /> Numbir of living units: —/— Number of ms <br /> 3 ' `7S <br /> CF s icter)of&ON to a WVth of 3 feet. <br /> � Water table depth <br /> SEPTIC TAMC. TypalMfq CspacityyNo.Compartments <br /> PKG. TREATMENT_PI_7 C1 t f 1 ��/� Method of Disposal <br /> Distance to nearest: Well )Foundation__L_1 �— Property Lins �� <br /> LEACHING LINENo-&-Length-of;lines F`- Tofal Iength/size i 2 �. <br /> FILTER BED 1_11<0istartcsito nearest,. L, Weil fylFaundation fid; __ Property Line <br /> ti <br /> SEEPAGE PITS � � Depth "y S Si'xe <br /> F <br /> SUMPS; r' Lt dista cs to nearest: Well-'i1ni2f Founda Pion�,/ Propsny Line <br /> DISPOSAL POND <br /> I hereby certify that I have prepared this application and that the work will be donvin accoitlance"with'San'Joa�uin'caiirity ordinances, state laws, and <br /> b <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work-foT`vvhich this permit is issued. I shall not <br /> employ any person in such manner as to become subject to workman;st'compensation laws of California."'Contractor's hiring or sub contracting signature <br /> certifies the following: "I certify that in the performance of the work foi which this permit is issued`I`shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t all to �5quir?l inspections. Complete drawing,onleverse side. t <br /> � � ��'f . Date• <br /> Signed t� JJ Title: <br /> 0 FOR,,,DEPARTMENT USE ONLY /l 7 <br /> A \'% Y it <br /> M Application Accepted by Date 6 - T Area �f <br /> { "+..i / J <br /> 49or Grout inspection by Date �SFinal Inspection by Date <br /> I� ' <br /> Additional Comments: <br /> It <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> r.l 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 2rY�j <br /> FEE AMOUNT OtIE' AMOUNT REMITTED CASH RELl* CEIVED BY OATS -,PERMIT'NO. <br /> INFO . <br /> . EN ty31IRtY.+ietil <br /> EM t476 <br />