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APPLICATION FOR PERMIT <br /> r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PT iMIT ESKMRS l YEAR PROM DATE ISSUED <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 LHefafl�th Services. <br /> Job Address 7� r v Y City Lot Size/Acreage <br />{ Vel r) Address Phone <br /> Owner's Name /J --- -�J <br /> Contracto l Gloss �rcm�S Address 53 . lF f nil License No. _W�hone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT P DESTRUCTION 0 Out of Service Well <br /> PUMP INSTALLATIO SYSTEM REPAIR C OTHER 0 Monitoring Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS y <br /> L'l Industrial -K-Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> 6'-�Ornestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> I Public i-1 Other p pelta Depth of Grout Seat 1 b Type of Grout.2dria{ +Ak <br /> Cl Irrigation _.Approx. Depth 0 Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump Ste+ H.P, t/ ` State Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 feetA <br /> Installation-will-serve:-Residence_ Commercial� - Other <br /> Number of living unite: Number of bedrooms �; ~ <br /> Character of soil to a depth of 3 feel: Water table depth <br /> SEPTIC TANK. C1Type/Mfg eCepacity No. Compartments <br /> PKG. TREATMENT PLT, Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 W <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, and <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 shell 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 compensa• <br /> tion laws of California." T <br /> The applicant must call for al equirad inspections, Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area- <br /> Pit <br /> rea Plt 0VT3rout Jnspection by Date ~Final Inspection by Date 2 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PU C ALT SERVICES ; <br /> v v .ENVIRONMENTAL HEALTH-DIVIS N PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOR 2008, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ()ATE PERMIT NO. <br /> i . EH 17.2/IRE Y. <br /> CH <br /> 31.2E <br /> f � <br />