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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY P[]BLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201. <br /> (209) 468-3447 <br /> 41 PIMIT, EXPIRES I YEAR rROM DATE ISSUER <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 compliance with San Joaquin County Ordinance No. 51+9 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address I l City Lot Size/Acreage rC'iY <br /> u / <br /> Owner's Name /' Address �67 a �' ��� �f t�� Phone N <br /> ContractorIVC44: �� "` II _ '� �� `��±License No. Phone l e f <br /> Address <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT f-1 OESTRUCTtON ❑ Out of Service Well 0 <br /> PUMP INSTALLATION Oe SYSTEM',REPAIR C1 OTHER 0 Monitoring Well 0 <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 J �� <br /> In Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing ? <br /> t_y Domsatic/Private e] Gravel Pack ac._.�� Type of.Casing Pv� - Specifications <br /> M Public CI Other 0 Delta of Grout / Type of Grout \ <br /> C� Irrigation pprox, Depth. n Eastern Surface So Installed <br /> Repair Work Done U ype of Pump S�°rA.h H.P. tate Work Done _ p <br /> Well Destruction Well Diameter 6'" -Sealing Material & �l <br /> Depth ��' -Filler Material & h <br /> TYPE OF SEPTIC RK: NEW INSTALLATION❑ REPAIRlApOIT10 ESTRUCTION CI (No septic system permitted it public sewer is <br /> available within 200 feet) <br /> i. Installation will serve: a —; Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> : 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FILTER BED CI Distance to nearest: Well Y Foundation Property Line <br /> SEEPAGE PITS it Depth Sue ° Number 1 <br /> I SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i Z <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 shall 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 /> tlon laws of California." <br /> The applicant must cell for all required ins coons. Complete drawing on reverse side. <br /> c U <br /> Signed t � � Title: Sa1�� �� V� �� Date: �0� <br /> FOR DEPA US_E1.ONLi' <br /> d .. fir <br /> Application Accepted by D*ata Area <br /> Pit or Grout Inspection by Date Final Inspection b Oat <br /> + <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 <br /> FEE <br /> INFO DUN T DUE AMOUNT REMITTED CASH RECEIVES) BY DATE CK 9 PERMIT'NO. <br /> oy f <br /> i + Eli 13-24 111EV.t/A$) '�S <br /> EM .CJt`J � G� [l} ?0 v4 <br /> ;4•Ie O`^ <br />