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APPLICATION FOR PERMIT x,% <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESUlm <br /> " <br /> ENVIRONMENTAL HEALTH DIVISION � 1 <br /> P O BOX 2009, STOCSTON, CA 95201 MAY 6 19p'1 k <br /> (209) 468-3447 ENVIRONMENTAL HEALTH <br /> Y3 R FROM DATE ISSU PERM1-TVSERViC.Fo <br /> +wL (Complete in Triplicate) a <br /> Application is hereby mode to San Joaquin County fors 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 Ban <br /> Joaquin County Public Health services. <br /> � s <br /> Job �ddress City Lot Size/Acreage <br /> Owner's Name Address , C j 4,! �,(9 <br /> � --� . _- ���...�._. Phone <br /> Contractor Address License Noiaaxs 7b 1 Phone <br /> TYPE,OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT nEIESTRUCTION Cl Out, of Service Well 17 <br /> I� PUMP INSTALLATION ❑ S''S"fEfN REPAIR OTHER ❑ Ilonitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD, i.PROP.`LINE <br /> � - FOUNDATION AGRICULTURE WELL OTHER WELL ; PITS/SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ICONSTRUCTI~SON SPECIFICATIONS <br /> 0 industrial Open Bottom ❑ Manteca 'Dia. of Well Excavation <br /> ! pia. of Well Casing <br /> G poinesOc/Private L1 Gravel Pack 0 Tracy =Type of,Casing Specifications <br /> D Putilfc <br /> El Other 0 Delta Depth of Grout Seal Type of Grout <br /> —Approx.frripation ADept ❑ Eastern Surface Setul Installed by W I <br /> RepairkTypeH.P. <br /> Wark Dona U of Pump � �- a State Work porta_ <br /> Welt Destruction O Well Diameter IQ Sealing Material i Depth > <br /> Depth s00 Filler Material i Depth <br /> TYPE `OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION Cl (No septic system permitted if public sewer is <br /> � available within 200 feet.l <br /> Instillation will serve: Residence— Commercial— Other _ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fast: ,^ ,r � r_ <br /> Water table depth <br /> SEPTIC TANK O Type/Mfg '� v Capatity� �' No. Compartments <br /> PKG. TREATMENT PLT, ❑ <br /> J _ <br /> Method of Disposal <br /> Distance to nearest: Well Foundati6h Property Line <br /> LEACHING LINE Ll No.A.Length of lines ' <br /> -... .,- Total length/size <br /> FILTER BED C7 Distanci to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS p Property Lina <br /> I hereby`certifythat 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 thi San Joaquin County <br /> Horne owner or licensed agent's signature canities the foilowjng: "I certify that in the performance of theworkfor which this permit is issued; I shall n <br /> employ any person in sucq manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> eanifies the folio : 'I certify that in the performance of the work for which this permit is issued, I shall em to <br /> tion laws o li or a." # p A Y persons subject to workman's compensa- <br /> ..� <br /> y <br /> The appfica at call for all requi inspactio Complete drawing on r ve se ;de: <br /> Signed Title; <br /> 1 Date: <br /> FOR DEPARTMENT SE ONLY <br /> .� <br /> Applicati)n Accepted by f1'Y <br /> pate f <br /> ` Area _— <br /> Pit or Grout Inspection by: Datew Final Inspection by <br /> Additional Comments; ! <br /> I <br /> Applicat - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE . E AMOUNT REMITTED CK <br /> INFO AMOUNT DUCASH RECEIVED By DATE PERMIT'NO. <br /> EH f344IPEV.,rn5i <br /> EH;..m. ��.� -3 1 <br />