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APPLICATION FOR PERMIT <br /> 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 9.5201 <br />` (209) 468-3447 II <br /> r <br /> 'R IT EXPIRES 1 <br /> YEAR eROM <br /> 3~? i�=� ffrb [rti1 <br /> (Complete in Triplicate) <br /> Z3. _YY P4O.S= r <br /> Application is hereby made to San Joaquin County for a permit to construct and/air 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 Services k <br /> Job Address �y ' W City 010 Lot Size/Acreage l 1619 <br /> -977170e- � �� Address3 �. a -2-2 <br /> Owner's Name - Phone <br /> I Contractor •C—� P` Address ?`i1 O E LST License No. Phone 3. <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D t DESTRUCTION)CII out of Service well 0 <br /> :1 ,�3 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Monitoring Well L� <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 /> f Cl Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br />` U Domestic/Private 0 Gravel Pack C1 Tracy Type of Casing Specifications , <br /> if M P is 11 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> II CuL act r. _ _Tc1XAIAI� <br /> Irrigation Approx. Depth d Eastern 5uriace Seal Installed by _ )) <br /> Repair Work Done U Type of Pump H.P. State Work Done a /l <br /> W411 Destruction Well Diameter Sealing Material 4 Depth } <br /> i <br /> Depth Filler Material i Depth <br /> 1 <br /> TYRE OF SEPTIC WORK; NEW INSTALLATIOD REPAIR/ADDITION Ci DESTRUCTION GIN septic system permitted if public sewer ;s <br /> available within 200 feet.) <br /> I <br /> Installation will serve: Residence^ Commercial— Other , r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Ij. Water table depth �\ <br /> SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments l <br /> PKG. TREATMENT PLT. C) Method of Disposal 1 <br /> Distance to nearest: Well Foundation. `Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> k FILTER BED n Distance to nearest: Well Foundation i4 Property Lina ' <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS LI Distance to nearest: Well 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, 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 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 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> lion laws of California," " <br /> The applica ust cat 11 required ins c ' ns. Complete drawing on reverseye. <br /> e. f q I <br /> Signed X Title: ., T Date: l L r <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Date 11;Z%01 t Area / <br /> Pit or Grout Inspection by Date Final Inspection by'11�1 Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Spilt JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO NkOYNT DUE AMOUNT REMIT7ED CASH RECEIVED BY DATE PERMiT NO. <br /> . EH 1,3•74iREV.t/n510 Q ' rc'! l� 1�� leil- ort/• ,b <br /> EM 0;l•1a V <br />