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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES QC 05 wo)� <br /> ENVIRONMENTAL HEALTH DIVISION 0 +�� <br /> 445 N SAN JOAQUIN, PHONE (209)468-342 t <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> { S� <br /> �t. <br /> PERMIT E%PIRES I Y FRQM DATE I SII <br /> (Complete in Triplicate) <br /> Application is hereby made Ito San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in coMlience with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ` �O f, <br /> >v X7/1 �r ��sZGj _ City r7gr- r7 Lot Size/Acreage <br /> Job Address I <br /> >(\\\ !� �"1 _ Address _ Phone <br /> `Owner's Nama R v1 <br /> I6ontraclor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEIN"WELL ❑" ervice-well 0 <br /> WELL REPLACEMENT [-1 DESTRUCTION ❑ �t"��itoring hell ❑ <br /> PUMP INSTALLATION O STEM REPAIR D OTHER C7 <br /> DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWEA LINES <br /> FOUNDATION � AGRICULTURE WE 'OTHER WELL _PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA S7RUCT1 SPECIFICATIONS Dia. of Well Casing <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavate <br /> Specifications - 1 <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tr Type of Casing <br /> (_I Other alta Depth of Grout Seal Type of Groutt} <br /> 1'1 Public v- <br /> I I Irrigation Approx. 0 1 1 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of - p <br /> H,P. <br /> State Work Done <br /> Sealing--Material A Depth <br /> Well Destruction D Well Diameter" -. <br /> Piller Mat'ei"ial i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTIO iNoilable sept within 200 permitted if public sewer is <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: " Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity Na. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE [DNo. b Length of linea Total Iengthlsi:e <br /> FILTER BED �,.._ ❑. Distance to nearest: - Welt "-"Foundation .Property Line" - - <br /> SEEPAGE PITS i 1 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hat the work will be done in accordance with San Joaquin county ordinances, slate laws, and <br /> I hereby certify that I have prepared this application and t <br /> rules and regulations of the San Joaquin County <br /> Homs owner or licensed agent's signature certifies the following: "1 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 subcontracting signature <br /> j certifies the following: "I certify that in the performance of the work for which this permit is tuned, I shall employ persons subject to workman's compensa <br /> "tion laws of California.., <br /> The applicant Call f all uir pgctions. Complete drawing on reverse side. <br /> \Si9ned ' Title: [. I� - Date: <br /> EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> 'Al <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> M <br /> Additional Comments: <br /> j Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 4 Box"2009, Stkn, CA 95201 <br /> K 6 <br /> FEE AMOUNT DUE AMOUNT REL41TTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO �{� <br /> r r EN 1}24(REV.I/RSI IOD t if V 311? �✓ �` <br /> I EN 14-M <br /> i <br />