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APPLICATION FOR PERMIT <br /> SAN J•OAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION � p[�,J <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 4683447 ' <br /> PPRI[IT EXPIRES 1 YEAR FROM DATE ISSUED APR � 19�r_ <br /> (Complete in Triplicate) <br /> Application is hereby ma4e,to San Joaquin County for a permit to construct and/or inat&lV%VPQWM. cribed. This <br /> application is made in compliance with San Joaquin County Ordinance No. 544 and 1862 and th >f���UWne of San <br /> Joaquin County Public Health Services,. 7 / � S <br /> Job Address .. S�� �� (/�E r ltl I15!V L -42 City " Lot Site/Acreage <br /> Owner's Name CaLa I Ui.. Address _7� l :Sc S'` "_ ��`^" Phone <br /> Contractor Address Z� _ _ License No. = Z Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Weil ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER g1 Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> W� FOUNDATION _. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [r <br /> F1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia, of Well Casing <br /> U Domestic/Private 9 Gravel Pack ❑ Tracy Type of Casing --,�4— POCK Specifications <br /> IO Public f.] Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Iffigation is ",,J�....,,Approx. Depth §6 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump ___ H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material A Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR1ADDiTION Ll DESTRUCTION CI (No septic system permitted if public sewer is �}� <br /> r available within 200 feet.) <br /> Installation will serve: Residence— Commercial_,__, Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth ) <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, [1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line ! <br /> 1 <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation 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, 0-nd <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 /> 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 compenss- <br /> tion laws of California." <br /> The applica usi all for all required in c . s Complete drawing on reverse side. <br /> Signed Title: _ —/�' L_�____ Date: 4� `�y <br /> A, <br /> _ FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dat 4 r I Area <br /> Pit or Grout Inspection by f Date Final Inspection by Dats / <br /> Additional Comments; <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 <br /> FEEC11 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK H Ft EIVED BY DATEnnnnrrrr PERIMIT'NO. <br /> 4-8 <br /> CH A•26 f I <br />