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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 /> PJ O W ( <br /> P O BOX 2009, STOCSTON, CA 95201 <br /> i ck— 3.C r <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V-,,- A� <br /> 4 (Complete in Triplicate) <br /> Application is hereby made to Sen 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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health 8ery css�Ify- y <br /> Job Address / ' r �"'" " City Lot Size/Acreage '2 /l ->50 <br /> Owner's Name S Address Phone <br /> Contractor �,�A Q—�`-' Address 3 d r L License No. � 3 Phone ''" <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Cl out of Service hell ❑ <br /> PUMP INSTALLATION Cl SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> 3 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fC7 Domesticipfivate 0 Gravel Pack n Tracy ' Type of Casing_ Specifications <br /> 1'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ____-Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done ~' <br /> 1 � Sealing Material i Depth <br /> Well Destruction ❑ Wall Diameter <br /> k r Depth Filler Material &'Depth <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION 1 I DESTRUCTIONX INo septic system permitted if public sewer is <br /> �( available within 200 feet. <br /> installation will serve: nce -!� Commercial— Other <br /> Number of living units: Number of bedroo s 71 _ <br /> Character of soil to a depth of 3 feet: C t Water table depth .� <br /> SEPTIC TANK.'' ❑ Type/Mfg Capacity No. Compartments <br /> i PKG. TREATMENT PLT.Irl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 6 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Lina <br /> _fSEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 /> F 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 performance of the work for which this permit is issued, I shell employ persons subject to workman's compenss-r <br /> tion laws of California." <br /> 1 The.applicent must ca aB req inspections. Complete drawing on reverse side. p ry <br /> Signed Tij� <br /> de I <br /> � �C� �� CJ�I�J <br /> Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by lase 3,tAPAP„ Date -IQ Area 0 7S <br /> t Pit or Grout Inspection by Date Final Inspection by Date o l 4Z <br /> 1 <br /> E Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 1445 N San Joaquin, P 0 Hoa 2009, Stkn, CA 95201 <br /> r FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> I <br /> • EN12.24(REV.1iti6) 7r/r � � +�/7�y/r <br /> t <br /> EH 14.26 1 •� l I �� - <br />