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APPLICATION FOR PERMIT <br /> SAN SOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> fff UP O BOX 2009' STOCKTON� CA 95201 1� D <br /> (209) 468.3447 <br /> PM 3SUIM <br /> �� ��/•�-f„�__�y�� (Complete in Triplicate) <br /> Ap'p icat oa is hereby made tf Sant/Joaqui County for a permit to construct and/or install the work Lerein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin C Public Healttfh Services. <br /> �w <br /> JoD Address City_ Lot Size/Acreage <br /> �!n <br /> q _ Address-N m0 . Com-- a s�4 Phone <br /> Owner's Name r r ' L - <br /> Contractor <br /> n Address t License No. Phone9..t <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK + f— SEWER LINES + S�t DISPOSAL FLD- {'Sof PROP:.JLJNE`- _ <br /> r <br /> FOUNDATION '�" �r AGRICULTURE WELL OTHER WELL �r PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS GtIC)t soon <br /> r, Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of WeillCCaM <br /> U Domestic/Private M Gravel Pack D Tracy Type of Casing Specifications <br /> M Public I"1 Other ❑ Delta Depth of Grout Seal Type of Grout 5yionilf- S <br /> CI Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Z� k <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Wall Diameter Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADOITION 0 DESTRUCTION LI INo septic systam permitted if psrbtic sewer is <br /> available within 200 fast.) <br /> trtsiallation will serve: Residence.,.,.. Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feel: —Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linea Total length/sire <br />` FILTER BED 171 Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS If Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. male 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 she 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 /> eanifies 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 Cef' nice." <br /> The applic mu Gail for (requir intions. Complete drawing an reverse side. <br /> Signed IV Title: =,//1f�1_• Date: <br /> FO D RTMENT USE ONLY <br /> Application Accepted by Date U 2 Arita ` <br /> Pit or Grout Inspection by Date Final Inspecti n by DatY <br /> Additional Comments: -36 <br /> Applicant - Returc &U copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ` <br /> 445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201 <br /> FEE INFO AMOuNT DUE lAMOUNT REM/iTrEO K EIVEO BY DATE PERMIYNp. <br /> ,. <br /> . 1iN I�•21 rl1EV.r w�1 U <br />