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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 /> P O BOX 2009, STOCKTON, CA 95201 2,� � <br /> PERMIT EXPIRES I YEAR FRQM DATE ISSUED <br /> (Complete in Triplicate) <br /> 4 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. 5k9 and 11362 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ic— <br /> y Job Address Cit " LotSine/Acreage <br /> 4 e, <br /> owneis Name g ^ Addie"sus Phone 1 <br /> Con0actor <br /> Address J License No. Phone <br /> TYPE OF WELL/PUMP: _)NE WELL ❑ WELL REPLACEMENT C7 IWS <br /> DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM EPAIR'❑ # +" OTHER ❑ ldonitoring Well <br /> C7 <br /> ' <br /> DISPOSAL FLD. POOP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> I FOUNDATION y AGRICULTURE WELL OTHER,WELLu'fJ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL_ PROBLEM AREA C CTION SPECIFICATIONS #� <br /> C! Industrial ❑ Open Bottoni ❑ Manteca Dia. of ell Excavation E F +� Dia. of Well Casing "ry <br /> �3 OomesticlPrivats i❑ Gravel Pack ❑ Tra^„y ;Type_ ._Casing____' Specifications v <br /> f l'i Public ! n Other n <br /> Dept of Groult Seal Type of Grout <br /> } I I Irrigation ,. �.Approx. Depth 76) <br /> Eastern, I.Su ce Soul lnstalled by <br /> i a I eft:P, ' -State Work Done <br /> Repair Work Dane U Type of Pump t r ,, <br /> Well Destruction ❑ Well Diameter I Sealing Hateri". i t Depth . <br /> ! I Depth <br /> j Tillert t4terial Depth .. _ k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION F ,DESTRUCTION 1`I,.INo septic system permitted if public sewer is 41 <br /> i svailabl wi in 200 feet.) <br /> Installation will serve: Residence Y Commercial Other <br /> t { <br /> Number of living units: Number of bedroomt <br /> 'Character of soil to a depth of 3 feet: Water tabl4idepth F <br /> SEPTIC TANK ❑ Type mig C �_ No. Compartments, i} <br /> PKG. TREATMENT PLT.❑ Method of Di <br /> lip`sal_' k <br /> Distance to nearest: Well Foundation +r -Property Line <br /> LEACHING LINE ❑ Na. 8 Length of lines ITrT- al,length /size t <br /> FILTER BED ❑ Distance to nearest: Well oundation ``Property Line <br /> SEEPAGE PITS I 1 ! Depth Size <br /> SUMPS LI Distance to rtair `t: Well 10 undation TPropeity.L+ns <br /> DISPOSAL PONDS ❑ { <br /> I liereby certify that I have prepared this application arid that the work will be done in accordance with San Joigi county ordinances�statte laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the tfollowing: "I certify that in the performance of the wdrk fo-rvWi hibh'this peimit is issued, 1 shall not <br /> r p <br /> -employ any person in such mpnnas 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.wi wkinan's compensa- <br /> tion laws of California." <br /> The applicant mus all for an requ!rWnspaqons.iComplete drawing on reverse side. <br /> Signedp Title: Dale: �. <br /> O MENT USE ONLY <br /> Application Accepted by Date y Area } <br /> e <br /> Pit or Grout Inspection by y Date { Final InspecTion byr.Data a TZI <br /> # �r <br /> Additional Comments: rl <br /> t Applicant - Return all copies to: San Joaquin County Public Health Services '. <br /> I Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 + <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY D TE PERMIT" 0. <br /> INFO <br /> :'E%17.24 11tEY,I/K 51 00 <br /> r' <br />