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APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVxCES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PF"IT E$pIRES 1 YEAR FROM_DATE 1.5SUJED l <br /> (Complete in Triplicate) <br /> Application is hereby mads to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> i application is made in comVitance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address VDl 2eAvCN iz i2D City F.C. Lot size Acreage <br /> Owner'sName . VIA dN <br /> � 1A �'�– Address 3 �A'� Phone – 773 <br /> Contrattor ��yam_�112�--Address License No. Phone ` <br /> ZSEZIi <br /> TYPE OF WELL/PUMP:– <br /> NEW WELL ❑ WELL REPLACEMENT n- DESTRUCTION ❑ Out M Service well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 <br /> I DISTANCE j0/NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f_OUNDATiON- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F C7 industrial © Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy ,,.._. Type of Casing Specifications <br /> M Public !1 Other Cl Delta Depth of Grout Seal Type of Grout. <br /> G lr6oation _.Approx. Depth ❑ Eastern Surface Seal Installed by <br /> e, <br /> Repair Work Done L3 Type of Pump H.P. -`•' State Work Done_ <br /> F t Well Destruction ❑ Well Diameter Sealing Material i Depth t <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JO -REPAIRlADOITION DESTRUCTION Cl (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence z Commercial— Other x <br /> Number of living units: Number of bedrooms . <br /> Character of soil to a depth"of 3 feet: . �� L P'`�' _ _ Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ :} Method of Disposal . '} <br /> Distance to nearest: Well Foundation Property Line <br /> F <br /> LEACHING LINE No. & Length of lines ._7t �- _ Total length/site 7S <br /> FILTER BED n Distance to nearest: Wel! ���' Foundation '3p Property Line 1 <br /> i <br /> SEEPAGE PITS t'I Depth Site';��ti,� Number <br /> SUMPS Distance to nearest: Well Int+-Foundation ��d Property Line <br /> i DISPOSAL PONDS la <br /> I hereby certify that I have prepared this applicaion 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 conifies the following: "I certlty 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 "'Contreetdir's hiring or•sub-contracting signature <br /> a certifies the following: -1 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." j <br /> The applicant must call for all required inspections, Complete drawing on reverse side. <br /> Signed x 5– <br /> D � Title' Dace: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date1 <br /> 2 <br /> L .Area �[ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant – Return all copies to: SAN JOAQUIN-COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMITISERVICES <br /> 445 N SAN JOAQUIN,:P O BOX 2009, STOCKTON, CA 86201 <br /> FEE7 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO � <br /> . Err 1 .21 IREV.1 J A 01 ) �o ' r i? O r" '", �z-ro��� o -3 2 <br /> EH:1.26 <br />