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APPLICATION FOR PERI[I T <br /> SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES <br /> ENVIRONMENITAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br />! P O BOX 2009, STOCKTON, CA 95201 <br /> PERS[ T ESP I RE S .1 Y FROld D TE SU <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 /> application is made in camplience with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 11 <br /> Job Address ut UfAeaCA.�i� PJ City t"_4 Lot 81ze/Acreage <br /> Owner.s Name +�+ E Address I Sit <br /> } Phone <br /> Conlfaclor ILr �AQa�t Addresswad License No.24(Z53(. _Phone 43$.Z <br /> � YPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ Monitoring Well <br />� 7OTHER O CJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial d Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 17 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I') Public fl Other f Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> X\ - <br /> Repair Work Done CI Type of Pump <br /> H.P. Stela Work Done_ \ <br /> Weil Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material B Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR 1ADDITili DESTRUCTION I I lNo septic system permitted if public sewer is 1 <br /> available within 200 feet,) <br /> Installation will serve: Residence 2LOI Commercial_ Other <br /> Number of living units: Numbei of bedrooms ` I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg "ti Capacity-LLeaD- No. Compartments �I <br /> PKG. TREATMENT PLT. ❑ Method of Di3poaal <br /> 1 <br /> Distance to nearest: Well Foundation_.�, property Line 3 � <br /> LEACHING LINE t6 No. & Length of linea <br /> al length/size S� <br /> FILTER BED Q Distance to nearest: .. Well. Foundation P] <br /> - � ._ Property Line�`,r;i��a.���/d� �• <br /> SEEPAGE PITS 11 Depth Size�� O t� <br /> Nu bar r <br /> SUMPS Distance to nearest: Well -1� Foundation-- Pro w <br /> DISPOSAL PONDS ❑ party Line _ (u�.Gf`�f/ <br /> r <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 it <br /> rules and regulations of the San Joaquin County <br /> Home owner or licenser!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 /> 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 /> cartifies 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 mus all f all req 'r inspections. Complete drawing on reverse side. <br /> Signed Title: `,7 SLD S3 g. <br /> �_ Date <br /> FOR DEPARTMENT USE ONLY a <br /> Application Accepted by ^ <br /> Date L Area_d aL- "tti2 <br /> Pit or Grout Inspection by Date Final Inspection74�`�- <br /> Date�` -Z.. <br /> Addhional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> fEE AMOUNT DuE AMOUNT REMITTED CK Ili <br /> INFO CASH RECEIVED BY 1 �DATE PERMIT'NO. <br /> . EM 1211AEV.1in51 <br /> EH 1{•4.20 (f <br />