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APPLI GATI ON FOR PEPW I T <br /> SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> -•...` ENVIRQNIIENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> { <br /> PMIT S%P I RES l Y FR M D <br /> (Complete in Triplicate) <br /> F Application is hereby made to Saul Joaquin County for a permit to construct and/or install the work herein described. This <br /> f 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 Health Services. i __ <br /> R <br /> Job Address " City Lr Lot Size/Acreage 1 <br /> Name ame ` c 2 <br /> s L!�/+ Address Phone <br /> Contractor Address G r <br /> License No � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17.7 DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS- <br /> L] Industrial fi Dia. of Well Casing <br /> f O Open Bottom <br /> C1 Manteca Dia- of Well Excavation <br /> Cl Domestic/Privet* ❑ Gravel Pack ❑ Trac <br /> f Y Type of Casing_ ' Specifications <br /> i'1 Public 1-1 Other Cl Delta Depth of Grout Seal f Type of Grout <br /> I I Irrigation _ —Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Dons;, <br /> Wall Destruction O Well Diameter Sealing Material i Depth <br /> F Depth biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION It.-DESTRUCTION € I (No septic-system permitted if pffblic s1!-7 <br /> tt available within'200 feet.l <br /> ` <br /> Installation will serve; Residence Commercial___ Other <br /> Number of lining units: � Number bf bedrooms �-- <br /> Character of M)N to a ' <br /> depth of 3 feet: <br /> SEPTIC TANK. l Water table depth r❑ Type/Mfg Capacity �. No. Compartments <br /> PKG. TREATMENT PLT.Cl ,i <br /> Method of Disposal <br /> Distance to nearest: Well Foundation . Property Line <br /> r. <br /> LEACHING LINE CL—No. A Length of linea r Total length/Slte ! <br /> FILTER BED <br /> ❑ Distance ta\nearest: Wel / Foundation . r - <br /> ! hProperty Line <br /> SEEPAGE PITS i kJ--Depth 5Size- <br /> SUMPS <br /> j 5ixe Number�^ <br /> SUMPS rL1 Distance to rtsaiest: Well �Q <br /> Foundation Property Lina r T i <br /> DISPOSAL PONDS ❑ <br /> Thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a <br /> rules and regulations'of the.San Joaquin Cond <br /> unty- <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• ntracting signature <br /> certifies the following: ­I tarn that in the rformence of the work for which this rri,it is issued, I shall employ tion laws of California." h Pe P y persons subject to workman's compensa• <br /> The applicant call f r MI rsquir spa ns- Complete drawing on roverse side. <br /> -. <br /> Signed Title: s�°tri <br /> Date: <br /> F R DEPARTMENT USE ONLY ! <br /> i <br /> Application_Accepted by . <br /> Date —S—Ci3 <br /> _ . <br /> Grout Inspection by ate Area��i?..._T►V- <br /> Sr Finial Inspection by -�Ge(� - nate <br /> T <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Savironmental Health Permit/Services J� <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 1 -20 tREV.find 1 1 fob 103 <br /> EH 14•20 1 <br />