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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <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 1s made in ccsgtllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public �He/a�lth.Seervices. <br /> Job Address (�TT-VS(.A2 ,d dd,,LJ- _. ___ CityLot Size/Acreage <br /> r Phone <br /> Owner's Nam Address <br /> P ��/! d �J <br /> Contractor a -, Address License No.7f&�7 0 Phone23?` <br /> TYPE OF WELL/ UM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER je Monitoring Well ❑ <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 /> CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public * 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ____Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump (-& H.P. _ State Work Dorte ZZ <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Filler Material i Depth --i <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 feet-1 <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Charaetef,of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg CEpacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Dis '"IDistance to nearest: Well Foundation Props?Ai <br /> V1 E IT <br /> RECEIVED <br /> LEACHING LINE ❑ No. E Length of lines Total lengt w2 <br /> -. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Pro tj Li <br /> I RAN A U IN COUNTY <br /> SEEPAGE PITS 11 Depth Sire NumfWSLIC HEALT <br /> SUMPS LI Distance to nearest: Well Foundation ENVI L1 <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. 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 /> canities 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 Californla." <br /> r. <br /> The applicant at call for NI required inspections, Complete drawing on reverse side.. <br /> Signed x� r Title: �adyl�� _ - Date: <br /> R DEP NLY <br /> Application Accepted byZDate Sr Ar <br /> Pit or Grout Inspection by Date Final Inspection by �` Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Healtb Permit/Services <br /> 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO /QH <br /> . EH1 <br /> 3-244I11EY.rieel -�� <br /> EH 14•3a <br />