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APPLICATION FOR PERMIT <br /> p - ! . <br /> SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES �� !% <br /> - 4 Q <br /> ENVIRONMENTAL HEALTH DIVISION' <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES 1 YEAR FROM DATE ISSUED , <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 coutpliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of•San <br /> Joaquin County Public Health Services. <br /> 1` <br /> Job Address c^ a City t Size/Acre age <br /> r, o <br /> Ownei s Name Address no <br /> i <br /> Contractor 4�-4ddress a 1ruddl LaLicense No 2,,73 Phone C. to <br /> TYPE OF WELL/PUMP: ' V NEW WEL WELL REPLACEMENT DESTRUCTION A Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRT OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NE6EST: SEPTIC TANK S LP- SEWER LINES DISPOSAL FLD. IM PROP. LINE !' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> iNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' Domestic/Private )l Gravel Pack ❑ Tracy Type of Casing_ L''yx, Specifications <br /> i'I Public E) 0141' fl Delta Depth of Grout Seal a Type of Grout ^ r, <br /> 'K Irrigation /,;�ZApprox. Depth I I Eastern Surface Seal Installed by- Zkz� <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Wall Destruction :r Well Diameter Sealing Material i Depth v <br /> Depth e10 C ' !'filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is', <br /> available within 200 feet.) <br /> Installation will serve: Residence____ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> ti PKG. TREATMENT PLT.❑ Method of Disposal f� <br /> -4j Distance to nearest: Well Foundation Property Line' r p <br /> (L'J1 <br /> LEACHING LINE . ❑ No. b Length of lines Total length/sire <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Coritractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit i issued, I shall employ persona subject to workman's compensa. <br /> tion is of Co'fornla." <br /> The applic st sup for all ted inspection Complete drawin re r si <br /> Signed Titl Q Date: <br /> _ r <br /> FOR DEP T USE ONLY Q , <br /> Application Accepted <br /> Ph o Grout spection Date Final inspectio Date <br /> Additional CommeMa: <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 K RECEIVED By DATE PERMIT'NO. <br /> INFJQ 0-0 <br /> • EN 13.24 MEV.t i M W W"11 � ' <br /> EH 14.1e ted-0-0 / 'r' ! Q�r <br />