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f APPLICATION FOR PERMIT <br /> I 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 /> ERM T EXPIRES 1 YEAR FROM DATE ISSIZED <br /> (Complete in Triplicate) <br /> te) <br /> i Application is hereby me a to Ss.n Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ocnpliance{with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> L <br /> - <br /> Job Address City Lot Size/Acreage <br /> _ a <br /> Owner's Name &J"Le—iCL, "dress Phone <br /> Contract Addre }' ,6 � �^ L'Cense N kms— PhoneAaw <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION= SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> 0 Ind al ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack :❑ Tracy Type of Casing_ Specifications <br /> i'l Public 1-1 Other 171 Delta Depth of Grout Seal Type of Grout <br /> F I Irrigation Approx... Depth I I Eastern Surface Senl Installed by <br /> Repair Work Done J Type of Pump H.P. Q�, State Work Done <br /> Wall Destruction ❑ Well Diameter Sealing Material i Depth —; <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> t .,�.J,y,,� -_ # available within 200 feat.] <br /> Installation will terve: Residence_ F Commercial_ Other - + <br /> Numtiir of living units. Number of bedrooms <br /> tCharactor of soli to a depth of 3 teat: tL - Water table dep!HEALTH <br /> d SEPTIC TANK. ❑ Type/MfgCapacity - ' No. Compartme <br /> PKG. TREATMENT PLT.Gl + h ;.� Method of Dia <br /> Distance to nearest: Well Foundation Property Line � <br /> f SAN <br /> LEACHING LINE Cl No. 8 Length of linesy Total length/size PUBLSOVICES <br /> FILTER 6ED Q. Distances to nearest: Well Foundation Property Line <br /> y A 1 <br /> SEEPAGE PITS `'{ 1 _Depth I' 1 Sirs Number x <br /> SUMPS _,LI ,;Distance to nearist: Well Foundation'. Property Line <br /> DISPOSAL PONDS�-:,'L7• <br /> I hereby certify that-1-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 Sin Joaquin County <br /> Houle 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 subcontracting 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 companse <br /> tion laws of California." 1 <br /> The applicant must squired inspect' . Complete drawing o verse side. -.. <br /> Signed TiNe; - Date: <br /> MORDEPARTIVIENT USE ONLY <br /> Applicstion Accepted by DateArea <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services i <br /> 445 N Saa,,,Joaquiri �O Hox 2009, Stkn, CA 95201 <br /> FEE AMO NT DUE AMO T REMITTED CA RECEF 0 BY ATE PERMIT'NO. A 11..y,,�,J// <br /> • EH 13.24 IREV.1 i N by I .. ' <br />�: 1iH il•2a P <br />