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APPLICATION FOR PERMIT <br /> �. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> L ENVIRONMENTAL HEALTH DIVISION PAYME) <br /> CA 95201 <br /> u <br /> 445 N SAN JOAQUIN, PHONE (2 -3420 <br /> P 0 BOX 2009, STOCKTON, CA 952 <br /> APR Q 5 ���? <br /> PERMIT E%PIRES 1 YE ROM DATEISSUEDSAN JOAQUIN C(is y s <br /> • (Complete in Triplicate) �PUBLICHEALTNgE.,. . .r <br /> Application is hereby trade to San Joaquin county for a permit to construct and/or install the w �, <br /> 1k bed. �fhis I <br /> application is made in cea�liance with San Joaquin county ordinance No. 549 and 1862 and the Rules and Regulat�l �f� ��l <br /> Joaquin county Public Health Services. OS2l�fU ! <br /> City I Lot Size/Acreage i <br /> Job Address <br /> Owner's Nameemaz <br /> Address Phone t <br /> `` ; CT>r'-�lificense No. Phone <br /> Contractor r Address. <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service well ❑ <br /> ttonitoring OTHER ❑ <br /> PUMP INSTALLATION � SYSTEM REPAIR L7 de Well <br /> DISTANCE TO NEAREST: SEPTIC TANK __4pL:— SEWER LINES DISPOSAL FLD. :F'ROPaLkNE;, <br /> _ •y <br /> NEAREST <br /> FOUNDATION�=� GRICULTURE Writ OTHER WELL P17S/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> i <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation <br /> Cl <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— Specificationsti <br /> IJKI'l Public 1-1 Other f1 Delta depth of Grout Seal Type of Grout <br /> I I Irrigation .. gppro Depth--L I Eastern~ ;Surface_Seat.ins_i_alled_by rS�� <br /> i }f p j State Work Done <br /> Repair Work Done U Type of Pump -'7—- Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter O <br /> i Depth Tiller Material A Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system perinitled if public sewer is <br /> available within 200 feet.) f� <br /> installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms 1 <br /> Character of soN to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments . <br /> 1 <br /> PKG. TREATMENT PLT. CI , Method of Disposal �. <br /> ( Distance to nearest Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. S Length of lines Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS 11 Depth Size Number" <br /> = "Ll�rDistanre-ta-nesrest:y-�rWeN ""'�'� FounAation ProPertY line <br /> DISPOSAL PDSAL PONDS ❑ <br /> that the work will be done in accordance with San Joaquin county ordrnancas, state ks <br /> w , and <br /> I hereby certify that I have prepared this application 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 shall not <br /> ' employ any person in such manner as to become subject to workman's compensation taws 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 parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required ins do . Complete drawing on reverse side. <br /> Signed X Title: Q-icA`tA- Date: <br /> FOR DEPARTMENT USE ONLY <br /> Dale Area 12-- — <br /> Application Accepted by n <br /> Pit or Grout Inspection by Date Final Inspection by <br /> u�tf Date— <br /> f <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services 4, <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PER <br /> INFO <br /> . EN 1341 IREV.111151 <br />