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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 0 BOX 2009, 'STOCKTON, CA 95201 <br /> PERM T EXPIRE YE FROM DATE S <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 /> mpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is made in co <br /> Joaquin County Public health Servic a. e / <br /> L i <br /> 1Scl'u r City Lot Size/Acreage <br /> Job AddressA y 36 '?3 <br /> Phone ; <br /> Owner's Name Address <br /> License No Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP?ti'e NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Ll <br /> OTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �� PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br />€ n Delta Depth of Grout Seal" Type of Grout <br /> I'1 Pubaic fa Other O <br />} k I irrigation Approx. Depth 4 ! Eastern Surface Seal Installed by <br /> H.P. State Work Done <br /> Repair Work Done L3 Type of Pump <br /> Sealing Material 4 Depth <br /> Well Destruction ,❑ Well Diameter biller Material A Depth <br /> Depth <br /> e <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAiRlADDITION STRUCTION I I No lrwithin 20c System0 feet.) it public sewer is <br /> available <br /> Installation will serve: Residence Commercial _ ther <br /> Number of bedr �a T <br /> Number of living units: r <br /> Character of sou to a depth of 3 fest: Water table depth <br /> r Capacity— No. Compartments <br /> SEPTIC TANK.. ❑ Typal Mfg Method of Disposal <br /> PKG. TREATMENT PLT.0 ." t ° <br /> t Distance to nearest: Well,_ Foundation Property Lina <br /> fA" length <br /> / <br /> LEACHING LINE L��Tfo. J4 Length of linea � �„'�_ Total leng � <br /> t.� `L[J ____— Property Line <br /> FILTER BED O Distance to..nearsst: Well 1 Foundation pe Y <br /> ✓f � 3. <br /> F SEEPAGE PITS IC��apth Sire Number � t <br /> SUMPS LI Distance to nearest: Wsit ` Foundation <br /> f k Property Line — <br /> DISPOSAL PONDS ❑ ' V <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, a d <br /> rules and regulations of the San Joaquin Countyv <br /> I Home owner or licensed agent's signature ceftifies thelollowing: "I certify that in the performance of t ,w <br /> he work for, hich 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 tho following:"1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- �.. <br /> tion'laws of Celifornli.", <br /> ,- <br /> ! the applican s II for I regti' iii coons. Complete drawing on <br /> {reverse side. <br /> �y Title: �CL` Date: <br /> i Signed - 1 <br /> �=, FO DEPARTMENT USE ONLY 2 <br /> F12 <br /> Dam.. O Area <br /> * "* `r <br /> I Application Accepted by <br /> Date ''I� Final Inspection by/✓''° Date 3 <br /> �P t or Grout Inspection by f--E-r- ;y -� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> R Environmental Health permit/Services , _,q•il\ <br /> 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 SVA\ <br /> FEzz <br /> CK RECEIVED By DATE PERMIT'NO. lV\ <br /> AMOUNT REMITTED H <br /> IN <br /> /0 <br /> . EM!}24 IAEV.I/�al S <br /> EH u•9s <br />