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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIMTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> �.' P O BOX 2009, STOCKTON, CA 95201 <br /> PFJMIT EXPIRES 1 YEAR FROM DATE <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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Services.Heaalth Services. <br /> KJob Address 4/ SS" �Lrf sm4lL /-f�,/ <br /> City A Lot Size/Acreage <br /> torivact, <br /> ner's <br /> Name Phone <br /> C �` vZ Address <br /> �''� Address <br /> License Na. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D POSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE`WELL OTHER WELL PITS/SUMPS <br /> + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S ► <br /> CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .1L <br /> L] Domestic/Privala ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ,J <br /> I') Public Cl Other I E Delta Depth of Grout Seal Type of Grout �1 <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done [P <br /> Well Destruction ❑ Well Diameter Sealing liaterial i Depth 1�1-.10 <br /> Depth biller Material A Depth S <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feetJ <br /> s 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 l� <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments lC <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> a <br /> Distance to nearest; Well Foundation . Property Line <br /> f <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size M1 <br /> FILTER BED n Distance to nearest: Well Foundation Property_Line - <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Lt Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ _tr+�V <br /> I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and v <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 fotfowing: "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 applicant at cal!forections. Complete drawing on reverse side. <br /> Title: Date: 62 <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> AraaA:D IJ <br /> Pit or Grout Inspection by Date Final Inspection by ' Q. Data <br /> f 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 0 Bore 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> EN M24 f! �,\ + <br /> • EW t1fRkV.ti�51 Q0 TSv V � <br /> t- <br />