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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / <br /> ENVIRONiMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 # <br /> x I)ENIT E%PIRES 1 YEAR <br /> (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 ccowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 <br /> Job Address /43 <br /> /LL �^ City Lot sine/Acreage <br /> _ s <br /> Owner's Name 1,A���� ��1-� Q Address Phone <br /> Contracto 1 Address � ` C -' Lir erase Na Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT rl DESTRUCTION Cl Out of Service well• CI <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑� .4 _. ' t OTHER ❑ Monitoring well J <br /> r C� <br /> DISTANCE TO NEAREST: SEPTIC TAW SEWER LINES DISPOSAL FLD. 7 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C7)- <br /> IL NTLNDED <br /> 7)_INT1rNDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ; D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [] <br /> Domestic/Private Cl Gravel Pack# _❑ Tracy—,r,,,_ .Type otCasing 5pecificationa __T__- i <br /> In Public C1 Other !❑ Delta Depth of Grout Seal _ f Type of Grout <br /> 0xi)-prox, Depth '❑ Eastern Surface Soul Installed by j <br /> € Repair Work,Done L3 Type of Pump H.P. _State Work Done <br /> Wait Destruction D Well 0f motor Sealing Material i Depth <br /> Depth ' Filler Material ; Depth <br /> TSEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION RUCTION M lNo septic system permitted if public sower Fs <br /> YPE OF ,O <br /> available within 200 feet) <br /> Installation will serve: Residence �' Commarciel ther <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 tool: { Water table dsath- <br />` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' <br /> PKG. TREATMENT PLT, CI Method of Disposal <br /> t <br /> Distance to nearest: Well Foundation Property Line <br /> L-EACHING LINE `J G1,-No.r8.Length of lines Total length/_size <br /> FILTER BED n Distance tofnearest: Well Foundation, Property Line <br /> I F <br /> 1P CSEEPAGE PITS i L-4Depth ___��_ Sire s N mbei -Lrna <br /> UMP5 L Wince to nearest:'""�µ�Well oun at,on' Progeny <br /> DISPOSAL PONDS ❑ <br /> Thereby-certify thaO hbve.prepared this application and that the work will be clone in sccordance'wiih'San Joaquin county ordinances, stale I ws,.andl ; <br /> rules and regulations of the San Joaquin County r f <br /> ll <br /> Home owner or licensed agent's signature certifies the following: "I cenity that in-the perf`o'rmance of the work for which this permit is tracts a nos <br /> employ any person in such manner as to become subject to workman's Compensation laws of California." Contractor's hiring or sub contracting signture- <br /> c reifies the following: " certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> t n of Colifornl <br /> The appli�an c `i fqr a r ed rn pec io late drawing an arse Sid [ <br /> r Date. <br /> Signs �� _ _ Title �. <br /> «� OR DEPAMENT USE ONLY q <br /> I <br /> Application Accepted by &tAA^1 <br /> € ~� Date _ �~ `� D• Area _ <br /> Pi or Grout Inspection try Date 7 Final,Inspection try TDate <br /> -- -- :' - <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC-HEALTH SERVICES <br /> y's <br /> fi� ;' j,•r"� { 4 , ENVIRONMENTAL HEALTH'DIVI9IUNYPERMIT/SERVICES y <br /> - 945 N. SAW JOAQUIW P•O BOX 2009, STOCKTON, CA 95201 - T� <br /> I 4 <br /> FEE AMOUNT DUE <br /> kAMOUNT REMiTTI t7 _ CASH I• RECEIYEO 8Y DATE Pt RM1T'NO. <br /> IMFQ <br /> . o <br /> EH 13.24 iREV.,/n5, id� • 1�'�� Y <br /> E1r;4.2e <br />