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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> r o P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT ESP I ES I YEAR FROM DATE 19JSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for permit to construct and/or install the work herein described. This <br /> r application is made in compliance vlth San Joaquin County ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I <br /> Job Address City Lot Size/Acreage <br />' <br /> Owner's Name �/ <br /> Address Phone 11! � -3� <br /> Contractor Address License No. Phone JV-!!f�3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Kell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0% ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Il Public Ci Other F1 Delta Depth of Grout Seal Type of Grout__ <br /> I 1 Irrivation _Approx. Depth I I Eastern Surface Seal Installed ll <br /> Repair Work Done U Type of Pump H.A. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth M <br /> Deplh Filler Material i Depth 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION DESTRUCTION I t III septic system permitted if public sewer is <br /> available within 200 feet.) <br /> s Installation will serve: Residence &_11Commercial Other y <br /> Number of living units: _�,_ Number f rooms .7 + <br /> f <br /> Character of$od to a depth of 3 feet: Water table depth <br /> SEPTIC TANK i❑ Type/Mfg Gpacit '' No. Compartments <br /> Y <br /> PKG. TREATMENT PLT:❑ Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Lina--�_ <br /> LEACHING LINE Er—No. b Length of lines 0 S r <br /> Total length/size <br /> FILTER BED -Q Distance to nearest: Well 1, <br /> Foundation • �� f Property Lins <br /> g. <br /> SEEPAGE PITS 44, -Depth <br /> SUMPS ;CI Distance to <br /> nearest: Wed l�p�_ Foundation Rt� Property Line O ^ <br /> DISPOSAL PONDS ❑ �' rY <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 perlormance of ths:work-for`slGf n thispermit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California.,, <br /> The appitcaptlinust call for I r trod insPections. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> ' FOR�LDEIPARRIMIEINT�u3� NLY <br /> Application Accepted by `. <br /> Ddte 'Area <br /> Pit tx Grout I G <br /> nttpection by Date Final Inspection by <br /> Additional Comments: E <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT REMITTED <br /> INFO AMOUNT DUE >< RECEIVED BY TE PERMIT NO. <br /> + N 17.24tAEV.F � <br /> N 1L-2a / <br /> I <br />