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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR F&QM DATE ISSUED <br /> t1 (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 made in comitance with San Joaquin County Ordinance No. 5I+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �u�p�y �i Cit Lot Size/Acreage <br /> Job Address T I: <br /> + r r e p <br /> ddress Phone <br /> Owner's Name � l <br /> J422-3f -2 <br /> of <br /> Contractor <br /> f s f Y� Address 1 .0 License No & ZZ Phone ��— Z <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 1.1 DESTRUCTION L1 Out btu Storing well ❑ <br /> PUMService well <br /> STALLAT��I//O�N O�� SYSTE�M/REPA_IR ❑ OTHER ❑ ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK) SEWER LINES �r�e _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e <br /> n Industrial ❑ Open Bonom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Qoestic/Private Gravel Pack 13 Tracy Type of Casing 7 pecificationa <br /> � m <br /> ['1 Public C1 Other �' n Delta Depth of Grout Seal ypero Grout \ <br /> -..- A'� pepth I I Eastern Surface Seal Installed by r r <br /> I I Irrigation �( <br /> Repair Work Done 044 �ump' <br /> I H.P. _ State Work Dona <br /> Well Destruction ❑ Well Diameter'l Sealing.Material i Depth <br /> Depth I biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-1 IREPAIR/ADDETION I I DESTRUCTION 1+1' INo septic system permitted if public sewer is <br /> available within 200 feet.) ; ;,. <br /> Installation will serve: Residence Commercial—. Otherr.-� <br /> Number of living units: Number of bedrooms i <br /> Character of soi4 to•depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK. ❑ 'Type/Mfg f Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> t Method-of Disposal a <br /> Distance to nearest: Well foundation Property Line <br /> th/size <br /> LEACHING LINE' ❑ No. b Length of lines _ Total Jeri g <br /> FILTER BED ❑ Distance to nearest: welt Foundation Property Line i <br /> SEEPAGE PITS I I Depth # Size Number <br /> SUMPS Ll Distance to nearest: Wall Foundation Property Line <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, an <br /> rules and regulations of the Son 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 cartify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compansa <br /> tion laws of California." <br /> The applicant must call for all rsquirsd inspections. Complete drawing on reverse side. <br /> Signed X Title: <br /> Date: kl <br /> FOR DEPARTMENT USE ONLY <br /> OW/App)�y tion Accepted b� Date Area ` <br /> I t l,� �G�'-//B _ <br />' r �Inspeetb Date by Final inspection by Date <br /> 071 Pit or <br /> Addnlortaf Comments:�a ��r !�^ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> N q ..... 445 N San Joaquin, P 0 Hoa 2009, Stkn, CA 95201 <br /> fEE AMOUNT DUE AMOUNT EMITTED GAS CEIVED BY D TE "RIIITN�JJ l <br /> . EM 14.28[NEV.�i/ (� �O oZ4, <br />