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APPLICATION FOR PER1dITRI >� <br /> h SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C "U` <br /> ENVIRONMENTAL HEALTH DIVISION NOV 5 1990 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 ENVIRONMENTAL yEALTH <br /> PERMIT- SERVICES <br /> REUIT EXPIRES I YEAR PROM DATE Issum <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 Is made in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services., <br /> Job Address of vCit Lot Size/Acreage <br /> Owner's Name ' Addre Phone6� <br /> o r r ddn ci No.=a Phone <br /> TYPE OF WELLIPUMP: NEW WELL O WELL REPLACEMENT _ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATISYSTEM REPAIR ❑ OTHER Q Monitoring Well C� <br /> DISTANCE-TO-'NEA'REST -SEPTIC'TANK-� "-'-S-EWER-L'1NES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED.USO TYPE OF WELL� PROBLEM AREA CONSTRUCTION SPECIFICATIONS ry <br /> n !n ustriil ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> stic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> Public r ' '� i-1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> M Irrigation_ 7 V Approx. Depth ❑ Eastern Surface Saul Installed by <br /> Repair Work Done 0 Typa•of Pump H.F� __ - i_ State Work Done ` <br /> Well Destruction O Well Diameter Sealing Material 6 Depth ..,4A� ( <br /> D"" ' " Filler Material 6 Depth, <br /> TYPE OF SEPTIC WORK,: NEWINSTALLATION L3 REPAIR/ADDITION 0 DESTRUCTION F-I (No septic system permitted it public sewer is <br /> j available within 200 feet.) <br /> Installation will serve: Residen4 i Commercial— Other 1 � l <br /> Number of living units: 'Number of 69drooms <br /> I IN <br /> Character of soil to a depth of 3 feet: Water table depth o <br /> SEPTIC 1'./1NK. ❑ Type/Mfg Capacity ' No. Compartments f <br /> PKG. TREATMENT PLT. 0 ; t Method of Disposal c <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE; ❑ No. & Length of lines Total length/size f <br /> FILTER BED [1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number J <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> 4_,DISPOSAL PONDS 0 <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 taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit it issued, I shall employ persons subject to workman's compensa- <br /> tion taws of California." 'I <br /> The applicant pyyst call for al4rul red inspections. Complete drawing on r erse side. <br /> Signed Title: Date: <br /> i FOR EPARTMENT USE ON <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by I Date Final Inspection by Date <br /> n . <br /> Additional Comments <br /> I <br /> Applicant - Return all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � { <br /> ii ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> J 445 H SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 8$201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . CH 13.24 IREV.tiny ' � - I` <br /> EH 14.2a FVO a??I+ proII <br />