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3 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> pT2NIT EUIRES 1 YEAR RQM I <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 i <br /> application is made in cdttpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. j <br /> Job Address2A b City Are adp oLot Site/Acreage g2e-'rYte'C_ <br /> '�� �Q 6 0 D g4ed �. Phone i <br /> Owner's Name � Address <br /> Gontractar, a h Address License No.c��93t Phone <br /> - ^ <br /> TYPE OF WELL/PUMP: NEW-WELLX WELL REPLACEMENT r DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALI.ATION>�, SYSTEM REPAIR Cl OTHER p Monitoring/Well <br /> DISTANCE TO NEAREST: SEPTIC TANK -110ig SEWER LINES DISPOSAL FLO. PROP. LINE � r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS If <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI?2N�S <br /> L1 Industrial. _ C],Open Bottom .— ❑ Manteca Oie. of Well Exc anon _ Dia, of Well Casing <br /> # �omestic/Private XGravei Pack `i=] Tracy Type of Casing �• Specifications <br /> C3 Public ('7 Other ❑ Delta Depth of Grout S pool�Cjro�l <br /> 0 Ir6oation 300/Approx. Depth Essiern f _Surface Seal Installed by ~ �(� K �S A� <br /> Repair Work Done U Type of Pump �� _ H.P. _' State Work Done <br /> Well Destruction D Well,Diameter Sealing Material A Depth <br /> Depth-"-- Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIA/ADDITION M DESTRUCTION CI lNo septic rystem permitted if public sewer is <br /> - available within 200 feet.) <br /> Installation will serve: Residence — Commercial— Other i <br /> E <br /> Number of living units: x�Number of bedrooms �. ,_ �.. _ <br /> ,�r r <br /> Character of soil,to a depth of 3 feet: Water table depth ' <br /> SEPTIC TANK= G Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING UNE ❑ No. & Length of lines Total tength/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth` Site Number <br /> SUMPS # Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ _ <br /> I hereby cartify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r <br /> rules and regulations of the Sen 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 n <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 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 /> f tion taws of California." <br /> The applicant must tail for all re aired inspections. Complete drawing on reverse side. <br /> Signs Title: S _ Date: <br /> FOR VAPARTMENT USE ONLY <br /> �]0 �� Area ` J <br /> Application Accepted by Date . <br /> j Pit or Grout Inspection by Y� Date Final Inspection by = Date (--3 �v <br /> Additional Comments: 1 mac►- f ��G _122" 2-0L - <br /> Applicant - Return all copies toil SAN JOAgU1N COUNTYSPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 98201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED RY DATE. PERMIT'NO. <br /> _41 �,�.,... INFO ! CASH G; <br /> . EH 13-24 IREV.r R 91 1 i n--� + �'�_3fJ^ l,"0 �p r•Z /� <br /> EH^,x•16 1 <br />