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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH Wit a <br /> ENVIRONMENTAL HEALTH DIVISI"N1 .._..^ <br /> 445 N SAN JOAQUIN, PHONE (209)463-342,�,` <br /> P O BOX 2009, STOCKTON, CA 95 D l } <br /> 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) -7��� <br /> Application its hereby tttade.to Ban Joaquin County for a permit to construct and/or i s tV9 .. <br /> �^ application is made in compliance with San Joaquin County Ordinance No. 549 and 186 one o an <br /> Joaquin County Pu12blic Health Servic e. <br /> s Job Address l 7 7S/Vi r I _ City ' Lot Size/Acreage 1,�Q a��' _ <br /> . ta0 <br /> Owner's Name �/ Address Phone <br /> Contract Address { y n 4 7 __ License No,3 212-Z Phone '9_S��S J <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service well ❑ <br /> F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring We. ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private.' ❑ Gravel Pack ❑ Tracy Type of'Casing Specifications <br /> I'l Public Cl Other fZ Delta depth of Grout.Seal Type of Grout <br /> 1 -Z <br /> I I Irrigation —.Approx. Depth i I Eastern Suffice Seal Installed by C <br /> Repair Work Done LJ Type of Pump H:P. State Work Done , <br /> Well Destruction ❑, Well Diameter Sealing Material i Depth <br /> r <br /> Depth Filler faaterial i Ddpth <br /> a ._ . _`: . <br /> Installation vrtll serve: R X L; DESTRUCTION E I (fYo septic system permitted it public sewer is <br /> TYPE OF SEPTICWORK: NEW INSTAL TION REPAIR/ADDI ION-.i- <br /> available.within 200 festa' <br /> i <br /> Residence _ Commercial_ Other <br /> Number of living units: _J_ Number of Wr9bms <br /> Character of,soq to a dap h of 3,feet: Water iabla,depth T' <br /> SEPTIC TANK, Type/Mfg Capacity �Q No. Compartments <br /> PKG. TREATMENT PLT.❑ / / Method of rDi�sp,oFsal <br /> 1 Distance to nearest: Welles foundation Property LineF <br /> LEACHING LINE N6. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well�, 70�' FoundationZ4 't Property Line t <br /> � I <br /> SEEPAGE PITS Depth Sire Dumber i <br /> SUMPS Cl Distance to nearest: Well Foundation __ 1+0 "t Property line <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 sub-contracting signature <br /> F 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 compensa- <br /> tion laws of Califoinis." <br /> The applicant s call for eq red Inspections. Complete drawing on reverse s,d <br /> Signed Title: -- - -- Y •�r Date: <br /> FOR DEP RTMENT USE ONLY <br /> r !� <br /> Application Accepted by Date ~ �' L / Araa <br /> r <br /> �Jor Grout Inspection by Oate2'r ' Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services I <br /> 44S N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE PERM1TT'NO. <br /> rM <br /> FH EH u•2,rrtEv,rigs, '� 01 1 <br /> Et4.2a jl�- <br />