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APPLICATION FOR PERMIT <br /> _ SAN JOAQUIN COUNTY PUBLIC HEATH SERVICES <br /> ENVIRONMENTAL*°HEALTH DIVISION <br /> y ; 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERIR <br /> 1[IT EXPIRES Y FROM D T I S <br /> h (Complete in Triplicate) <br /> l Application is hereby madeto San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is meAe in canpliance with San Joaquin County Ordinance No. 549'and 1862 and the Rules and Regulations of San <br /> . Joaquin County Public He LtIV Services. <br /> , a 1 City L Size/Acreage <br /> Job.Address Or+ d)Ct 1 <br /> ` . . --a1ao %A/ fa d <br /> 4 Phone <br /> Owner's Name �}� <br /> License No �'� 7.3 Phone` ! �_ bZ <br /> Cantrattor ress <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Weil n <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well <br /> ' SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST:{SEPTIC TANK _ PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> (1 pome6ticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> Cl pelta Depth of Grout Seat Type of Grout <br /> I'1 Public {71 Other <br /> k I Irrigation / _-._.Approx. Depth I I astern S urf ce Seal Installed b}I <br /> Repair Work Done i le <br /> E Type of Pump <br /> H.P. Stat4 Work nd <br /> p Sealing lfaterial & Depth <br /> Well Destruction ❑ Well Diameter hiller Material i Depth <br /> Depth <br /> TYPE OF.,SEP_TIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION l I Mafia seple tic bin m rented it Public sewer is <br /> I Installation will serve: Residence— Commercial— Other <br /> l Number of living units: Nu r bedrooms Water table depth <br /> Character Of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑; Type/Mfg Ca ity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑;, <br /> i Distance to nearest: Wel undation Property Line <br /> LEACHING LINE ❑¢ No. &'Length oi.lines Total length/size <br /> FILTER BED 0 Distance to rwla 06t: Well <br /> dation Property Line <br /> SEEPAGE PITS 11 Depth- Size Number <br /> SUMPS Ll' Dista Property Line <br /> ce tin"ice. Wall Foundation <br /> DISPOSAL PONOS. .__❑,{- _�_ - - -- <br /> I hereby certify that I have prepared this application end that the work will be dorsa in accordance with San Joaquin county ordinances, state laws, end <br /> . <br /> rules and regulations 1*xis of the San Joaquin County in <br /> Home owner o►I' gent's signature certifies Lha following: "1 Certify that m the performance of the work for wliieh thi6_perm�s issued, I shall not <br /> employ any n in such nnar as to become subject to work�rlen's compensition laws$f California° Contractor's:Niring or 00&-contracting signature <br /> CAI the otbwinq: "I a 'fy that in the performance he work for which this permit is issued,1 shall timpiay persons subject to rvorkrrltin's compansa <br /> tion laws California." <br /> The apps' ant mus ca r requk i m sat r v <br /> � ,�h/ _ <br /> Signed Title: pate: <br /> DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> �- <br /> r Data -� <br /> F Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P Box 2009, Stkn, CA 95201 ' <br /> FEE K RECEIVED BY ATE PERMIT'N0. <br /> INFO AMOUNT DUE AMOUNT REMITTEt? CA <br /> 9,6 <br /> . EH 1}24 INEV.1 Y 1151 ✓ ` i <br /> EH 14.26 �� <br />