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,I <br /> 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, 9TOCKTON, CA 95201 <br /> PERMIT E%PIRES Y I FR M D TESjJFJ <br /> (Complete in Triplicate) <br /> Application is hereby glade to.San Joaquin County for a permit to construct and/or install the.vora herein described. This <br /> application is made in Comrpliance vith.San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. qq <br /> Zveq Lot Size/Acreage <br /> Ff r City <br /> Job Address IL I? <br /> fJ <br /> Z C'09—' Phon <br /> / <br /> Ow is Name r ` <br /> /t� Address �O T <br /> Address License No.,?�F°1��f hone a <br /> Contractor <br /> WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <br /> OTHER ❑ Monitoring Well n <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR j1Y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ,�� OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Wel! Casing1� G <br /> C1 industrial Open Bottom _ ❑ Manteca Dia. of Well Excavation <br /> 7 of Casing— ar ld g- *!6Z?4 6M ifications <br /> Cl Domestic/Private ❑ Gravel Pack L7 Tracy y g— Type of Grout <br /> IF I'1 Public I-1 Other F1 Delta Depth of Grout Seal <br /> —.Apprax..Depth 1 I Eastern Surface Seat Installed by <br /> .6e Irrylation (� <br /> Repair Work Done LJ ,Type of Pump M.P. Sate Work Dona , <br /> Sealing Hsterial i Depth <br /> Well Destruction ❑ Well Diameter hiller Material 4 Depth <br />� Depth r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I iNBilsepttic systeThin m fm tied if public sewer is + <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 teat: O <br /> Ca <br /> "SEPTIC TANK. ❑ Type/Mfg pacity No. Compartments <br /> i Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> k Distance to nearest: Well .Foundation Properly Line <br /> LEACHING LINE Cl No.`b Length of linea w Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> ' SEEPAGE PITS JI Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hat the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and t <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 /> 4 certifies the following: '°I certify that'in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa <br /> f tion lawn of lif rnia." <br /> The applica m at 1 for all'equ inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> a,ri c OrC Date: Z/y 3 <br /> P�ARTMENT USE L 4 <br /> Application Acceptedby <br /> ,pate Area <br /> Data <br /> ���� _ It(r•+�rPrc:• S`f� d > t we!l �-.� - 93 — r <br /> �1 hi r Grout Inspection by o✓ L Date Fin Inspection by <br /> w b <br /> Additional Comments:- - _ <br /> - r S(c r /lam <br /> � Applicant - Return all cop"t7sJoaquin County Public Health Servic s s'�tysYha,rsa / <br /> Environmental Health Permit/Services <br /> 445.N San Joaquin, P O Box 2009, Stkn, CA 95201 -f,, (a a o(GZ'I" <br /> r PEE1( RECEIVED BY APERMIT N <br /> � AMOUNT DUE AMOUNT REMITTED DTE 0. <br /> INFO <br /> . EK 13.24IREV.liM5) WK <br /> EH 1478 C. '~ <br /> f <br />