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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> " -YEAR <br /> (Complete in Triplicate) <br /> Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. <br /> application is made in coup'liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San This <br /> Joaquin County Public Health Services. <br /> Job Address City-�'7�,_ _ Lot Site/Acreage <br /> II <br /> Owne►'s Name I-e.- Address � _. Phone ?Lr <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ClDESTRUCTION ❑ Out of Service We11 ❑ <br /> PUMP INSTALLATION 0 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 /> f-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CJ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> CJ Pril i"1 Other ❑ Delta Depth of Grout Seat Type of Grout <br /> �I trrioa0ation — Appro��. Depth d Eastern �, Surface Soul Installed"by <br /> Repair Work Done U Type of Pump Hp„ �' <br /> State Work pone <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depthi Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> .Installation will serve: Residence Commercial_ Other <br /> Number of living units: —'I Number of bedrooms <br /> Character of soil to a depth of'.3 feet: Water table depth <br /> SEPTIC TANK. Cl Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 i <br /> I; Method of Disposal <br /> Distance to nearest: Well Foundation Property Line _ , <br /> r <br /> - t <br /> LEACHING LINE — C1 No. & Length of lines ` <br /> .�," � Total length/size ! <br /> FILTER BED { n Distance to nearest: Well Foundation Property Line r <br /> SEEPAGE PITS 11 Depth Sixe �74 _ Number <br /> SUMPS <br /> 1 G. <br /> Distance to nearest: Well-•- Foundation/A` Property Line .-1 <br /> DISPOSAL PONDS i ❑ ` <br /> I hereby certity 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 CountyI <br /> Nome owner or licensed agent's signature certifies the following: ':I cortify.that in the performance of the work for which this permit is issued, I shall not I. <br /> employ any person in such manner as to become subject to worl�man's compensation laws of Cslifornia,'�Contractor's hiring or sub-contracting signature <br /> conllaws off011Owi n; 1-certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compens e <br /> The applicant must call for p11 required inspections. Complete.drawing.on.reverse.side.—. � f <br /> Signed </ -- <br /> 11 Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by .i rµ O <br /> Date Area <br /> Pit or Grout Inspection by pate "~ r <br /> - � Final Inspection b 10 t^ <br /> y Date (} <br /> Additional Comments; <br /> �- Applicant - Return all copies to: Q ' - "—C . - <br /> p SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 11 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES~ <br /> J 445 N SAN JOAQUIN., P}0 BOX 2009, STOCKTON,-'CA, 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED u CK <br /> INFO CASH RECEIVED BY ` DATE p PERMIT'No. <br /> . EH 13-241AEv.iixso f <br /> EN,x•26 <br />