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D <br /> APPLICATION FOR PERMIT qR <br /> SAN iaAQUIN COUNTY PUBLIC HEALTQijIWES �Jq fi5 <br /> ENVIRONMENTAL HEALTH DIVIST tF 7 /O <br /> 445 N SAN JOAQUIN, PHONE (209) f�8��&$0 <br /> P 0 BOX 2009, STOC%TON, CA ;gj_8 �fyy ffff <br /> PERMIT EXPIRES 1 YEAR FROM D T <br /> (Complete in Triplicate <br /> Application Is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is aerie in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County <br /> /Public Health <br /> DServices. <br /> Job Address / ` u`'�-E//art-tom'/h' CityLot Size/Acreage �OS Q-C/LRQ> <br /> C Y71-y <br /> _ <br /> Owner's Name 1k Address P, jPhone <br /> Conlracl/ sd��aAddress 6© <br /> CI0X ��/ 'l�O[✓--P License No__7 Phone�szes <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT p DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 0 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 /> n Industrial p Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> ('I Public I ) Other ll Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work.Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material L Depth \ <br /> Depth Filler Material i Depth X <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted d public sewer is lM,i <br /> available within 200 feet.) <br /> Installation will serve Residence� Commercial _ ther <br /> Number of living units: / Number of room / <br /> Character of sos to a depth of 3 fest: Water table depth <br /> SEPTIC TANK X Type/Mfg K Capacity , laO No. Compartments <br /> PKG. TREATMENT PLT.❑ / l Method of Disposal (eta <br /> Distance to nearest: Well ISO t Foundation 6 Property Line <br /> LEACHING LINE )71� No. 6 Length of linea Total length/sire x \( <br /> FILTER BED ❑ Distance to nearest Well O/�' Foundation /0 r Pro y I <br /> f party line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line 7C <br /> DISPOSAL PONDS ❑ 111 <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 Sen Joaquin County <br /> Home owner or licensed agent's signature canines the following: "I certify that in the performance of the work for which this permit is issued, I atoll not <br /> employ any person in such manner as to become subpct to workman's compensation Laws of California." Contractor's hiring or sub-contracting signature <br /> canines the following: "I cenity that in the performance of the work for which this permit is issued, I shall employ Persons subject to workman's compenu <br /> tion laws of CNifornis." <br /> The app7Acceptod <br /> t call to q i ed inspections. Complete drawing on reverse 1 <br /> 7OCJ�' <br /> Signed TitleDate: �JJFOR DEPARTMENT USE ONLY <br /> Applicatby @— Date _Area <br /> Pit or Grout Inspection byDate Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 'L1Ii/ 445 N San Joaquin, P O Bos 2009, Stkn, CA 95201 <br /> `� IHFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED eVDATE PERMIT�NO. <br />