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1 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 /> r PERMIT EXPIRES 1 YEAR FROM DATE I SUED <br /> 1. : (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County for s permit to construct end/or install the vork herein described <br /> This <br /> F1 application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations or San <br /> 4 Joaquin County Public Health Services. <br /> /11ob Address CityLot Size/Acreage <br /> Owner's Nam /Address "' Q2C��S _d_tZk Phone <br /> ConUactar �_� „` Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Wel. ❑ <br /> i <br /> itorng Well <br />� -- PUMP INSTALLATION ❑ SYSTEM REPAIR p OTHER ❑ Mon ❑ <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 /> L-) Industrial 0 Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> FM <br /> VI Public 1-1 Other (�l Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth L I Eastern Surface Seal Installed by C <br /> Repair Work Done L7 Type of Pump H.P. State Work Done _ <br /> Well Destnrotion ❑ Well Diameter Sealing Material i Depth <br /> P Depth Iriller Material i Depth ` <br /> IYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ! DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 260 lest.) <br /> s Installation will serve: Residence 4 Commercial_ Other <br /> Number of living units: Number of rooms <br /> j Character of soil to a depth of 3 feet: Water sable depth /�D <br /> t SEPTIC TANK. fl- Type/Mfg Cn ►' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method C2H <br /> Distance to nearest: Well 100 Foundation 3 0 Property Line LEACHING LINE f No. b Length of lines Total length/size� X LE71 <br /> FILTER BED 0 Distance to.nearest: Well 00 Foundation D Property Line <br /> tSEEPAGE PITS I:" -pth � S Size �b umber <br /> SUMPS Distance to nearest: Welloundsiaq,_ fJ_ Property Line <br /> DISPOSAL PONDS ❑ i. U r ;l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wit"an Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent'ssignature 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 /> x certifies the following: "I certify,that in the performance of the work for which this permit is issued, f shall employ persona subject to workman's compan&&_ <br /> tion laws of California." <br /> The applicant t call for all red ins ctions. Complete drawing on rev side. <br /> ignod Date:Title: +� <br /> FOR DEPARTMENT USE ONLY <br /> A ice' n Acc ted by L Date Z Area O <br /> Pit r Grout Inspection by Date 'q- Final Inspection by Date <br /> f� dditionaE Comrr+ants: <br /> Applicant - Return all topics to: San Joaquin County Public Health Services <br /> `r 11 Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE MOUNT REMITTED CKSFi RECEIVED BY DATE PERMIT NO. <br /> 1 f�V <br /> . EH 13-24lRl;Y.t/x51 © � <br /> j EH 14•ffi <br /> I` � <br />