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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION ` <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXP I RES 1 YEAR FROM DATE 109M <br /> M 7 <br /> (Complete -in Triplicate) <br /> ApplicaThis <br /> tion is hereby made to Sap Joaquin County for a permit to construct and/or install the work herein described. i <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Aegulationa of San <br /> Joaquin County Public Health Services. <br /> Job Address I City + Lot Size/Acreage <br /> ,Owner's Name Address �eJ� C: f V r� Phone ` 1 <br /> Contractor ,,R Address p_Ro` 7 License No. 13a!;Ls phone <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ -h WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q Monitoring Well n <br /> DISTANCE TO NEAREST., SEPTIC TANK, ' SEWER LINES — DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION.4`- AGRICULTURE WELL OTHER WELL PITS/SUMPS .� { <br /> INTENDED USE TYPE OF WELL " PROBLEM AREA CONSTRUCTION SPECIFICATIONS + <br /> ❑ Industrial i O Open Bottom p Manteca Dii. of Well Excavation Dia. 461 Well Casing w F <br /> r} Domestic/Private O Gravel Pack L1 Trac- <br /> Y f� Type of Casing_ Specifications <br /> I'1 Public f.3 Other 1�1 Delta Depth of Grout Seal Type..of Grout r <br /> I 1 Irrigation —.Approx. Depth 'I 1 Eastern Surface Seal Installed by { <br /> Repair Work Done U ` Type of Pump N.P. r State Work Done j <br /> Well Oestruction'� ❑ Well Diameter Sealing Material & Depth <br /> Depth F _Filler Material i Depth e { <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,I I tiREPAIR/ADDITION DESTRUCTION I F (No septic system permitted it public sewer is <br /> } available within 200 feet.l r <br /> Installation will serve: .Residence X Commercial— Other <br /> Number of living units: "{— Number of bedrooms ""c --- <br /> Character of soil to a depth of 3 feet: e-- Water table depth 4 <br /> x <br /> SEPTIC TANK. O Type/Mfg M Capacity No. Compartments <br /> PKG. TREATMENT PLT.D Method of DisposaE, <br /> v Distance to nearest sW11 Property Line <br /> LEACHING LINEw <br /> a.,8 Length of linea _ __ Total length/sixe s <br /> six <br /> FILTER BED <br /> (Distance istance to nearest; Wall Z `:, Foundation Property Line I <br /> SEEPAGE PITS <br /> pthra _ Number <br /> SUMPS M _ tLI tstance to nearestt Well Foundation Property Line ° f <br /> DISPOSAL PONDS <br /> I hereby certify that i have prepared this application and that the work will be done in accordaf t e with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sin Joaquin'Caupty r- <br /> Horne owner or licensed agent's iigr aturs certifies'the following: "t certify that in the performance of the work for which this permit is issued, I shall not <br /> o bec <br /> -employ any person in such manner as tome subject to workmen'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 /> tion laws of California." <br /> The applicant must call for an fired in ctions. Complete drawing on reverse side. <br /> . ! Title: Date: `��``�� �—• <br /> �. R DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Area <br /> Ph r Grout Inspection by ate Final Inapectian_b Date <br /> Additional Commenta:t <br /> Applicant -`Return all; copies- , q i�y thl'se3pvi <br /> . ' Environmental Health Permit/Serv,ices <br /> 445 N San Joaquin, P O Box 2009,?;Stkn, CA 95201FEE <br /> • 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br />• <br /> EM 13-24 IFIEV.I/h5), �� 'y-- <br /> - <br /> �f <br /> EM 11.20 , �or. �"��/F - 7 '�• I <br />