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APPI,ItATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT ESPIRES ] YF <br /> 49 FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in com�liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage t <br /> ,A1 ` 3 <br /> sPhone `r <br /> Owner's Na r l ':"teAddres ` <br /> / hay <br /> C n r rear f i N � <br /> Phon 3 1 r 24 <br /> +r s <br /> TYPE OF WELL/PUMP: NEW WELL 0 � '`-WELL-REPLACEMENT , + r DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIOr+f_-tzr -~ SYSTEM REPAIR CI OTHER ❑ Monitoring Well C3 { <br /> DISTANCE TO NEAREST: SEPTIC TANK ! `SEWER LINES �•� DISPOSAL FLD. PROP. LINE <br /> /FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r j <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> 411dustriel ❑=Open Bottom m_.,0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mastic/Private ❑'GG/ravel Pack ❑ Tracy `iype of Casing_ Specifications <br /> 1 <br /> '1 Public f`3"0ther n Delta-� Depth of Grout Seal Type of Grout <br /> I Irrigation— Approx. De 11 rn Surface Soul Installed,by } <br /> Repair Work Done U Type of Pump H.P. r -- State V11ork Don <br /> Wel! Destruction ('❑ FWeII Dia Sassing-,>faterial_&-Depth <br /> tFiller Material i Depth <br /> _ -_Depth <br /> /TYPE OF SEPTIC,WORK: NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTION I I<(No septic system permitted if public sewer is <br /> I 'available within 200 feet.) <br /> Installation will serve: Residence„___. Commercial_ Other t <br /> Num�ir of living unitti:"'"-"'�—"Number of"bedroor+is <br /> Char&Cter/of <br /> loll to.a"depth of 3}set: Water table depth <br /> SEPTIC-TANK. ❑ Type/Mfg Capacity — No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of linea Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> rSEEPAGE PITS , t I I \both. Size Number <br /> s <br /> SUMPS �. ' I•._,.Distance_toawarest:__Wall. _F.oundation. - -- Property-Line --- --- <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations-of the San Joaquin county <br /> Home owner or licensed agent's signature candies 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 signstut <br /> candies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to rkman's compensa- <br /> tion laws of California.' <br /> The applies m at call 'ad in coons. Complete drawing jono�srseLside6., " <br /> Sig 1.4Title. Date: <br /> Q FOR DEPARTMENT USE ONLY I] �} <br /> Application Accepted by „� Date `-�` Area <br /> Pit or Grout inspection Date Final Inspection by Date <br /> Additional Comments. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental. Health Permit/Services <br /> 4515 N San Joaquin, P Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'N0. 3 <br /> IN[F�O h �J <br /> . EH 13-24 1REV.ries tE� ,0v X <br /> c EH 14.26 \ C1 <br />