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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION pcy- Ce <br /> tt- <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> �-1 <br /> P 0 BOX 2009, STOCKTON, CA 95201 -Q <br /> PERMIT EXPIRES 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 cccpiiance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> %ql <br /> Job Address - City 11 Lot Size/Acreage 7 <br /> F13?--31/o <br /> Owner's Name 4 tl!& ��. ah���e?Address e Phone <br /> Contractor _____ �1'Y1 e, _ Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well C1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O Monitoring well ❑ + <br /> DISTANCE TO NEAREST: SEPTIC TANK �. SEWER LINES �_ DISPOSAL FLD. PROP. LINE f <br /> ^FOUNDATION AGRICULTURE WELL OTHER WELL 'PlT5/SUMPS' - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ,r S <br /> D Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation I Dia. of Well Casing 1 <br /> "54-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public Cl Other f'1 Delta Depth of Grout Seal Type of Grout <br /> �#Irrigation _.Approx. Depth I'I gEastern Surface Soul Installed by <br /> Repair Work Done 9 Type of Pump H.P. _T State Work Done_ IF <br /> . <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION I I DESTRUCTION I i iNo septic system permitted if public sower is <br /> available within 200 lest.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sod to a depth of 3 feet: Water bb 4ept#> r <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Com rirrlents <br /> PKG.'TREATMENT PLT.❑ Me� osal <br /> Distance to nearest: - Well Foundation Property t, 7 R 404? <br /> tY"J�v--wars,. <br /> LEACHING LINE C1 No. i Length of lines Total lengt# ml! rE <br /> FILTER BED ❑ Distance to nearest. Well Foundation iSl7s;LNE1sl 114 DIVic <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS _ LI- Distance to nearest: Well Foundation Property Line <br /> -DISPOSAL PONDS Y❑ <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, an <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, 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 subcontracting 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 compenss- <br /> tion laves of California." <br /> The applicant et cAll f co <br /> 1 required ins ons. Complete drawing on reverse side. <br /> Signed 'nL Title: L->&J_►��j J 1� _ Date: <br /> DEP E ONLY } <br /> Application Accepted by -0 Date Area <br /> Pit or Grout Inspection by Date Final Inspection Datq�Q I <br /> r <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, x 2009, Stkn, CA 95201FEE <br /> S <br /> INFO AM UNTf)ptJE AMOUNT REMITTED K ECEIVED BY 0 TE PERMi7'N0. <br /> Lor <br /> . EN 13-24 11MV.s 04 5 � v`� . 12 <br /> EM 14.26 W_ . 7w� /v V ��z <br />