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APPLICATION FOR PER7d I T <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, STOCSTON., , CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE \\ <br /> (Complete in Triplicate) <br /> 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 Coun y Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 93001 /v � � � City Lot Size/Acreage <br /> Owner's NameAddress Phone <br /> Contractor <br /> Address cense No �a � Phan � � <br /> TYPE OF WELT,/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION' ❑ Out of Service Well. 0 , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS ' <br /> INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial,_, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_� Dia. of Well Casing <br /> N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing k 71Specilications_' f <br /> I'3 Public [-I.Others n Delta IJ Depth of Grout Seal, � Type of Groui� l <br /> I I Irrigation _.Approx. Depth I I Eastem­m-" Su'-r ace Seal_Installod-by <br /> Repair Work Done U Type of Pump H.P. State Work Done `� a <br /> Wail Destruction ❑ Well Diameter Sealing Material i Depth <br /> '^,i ^ <br /> -f Filler Materi i-De thDepth <br /> F� <br /> TYPE-OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION 1No septic systersi.pe►mitted it public sewer is <br /> 'available within 2OO fest.l - <br /> Installation will serve: Residence-�( Commercial Other ? f <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br />` SEP'NeTANK. ❑ Type/Mfg Cap_aCitY �- �No. Compartments �� <br /> I PKG. TREATMENT PLT.❑ � / (. Method o! l <br /> f)istenco to nearest: k-Well r_J� Foundation Property Line <br /> rr _.. <br /> LEACHING LINE Cl No: b Length of lines Total length/size "1 <br /> FILTER BED '❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 'Depth 4a Sire Number Qf <br /> SUMPSC J Distance to nearest: Well Foundation Property Line _ <br /> DISPOSAL PONDS ,❑ <br /> `� ' <br /> I hereby certify that I have prepared this application end 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 /> a.. 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 workmen's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in'OW pbrformance of the work for Whish thin permit is issued,1 shall ampioy persons subject to workman's compensa- <br /> tion laws of Callfamia." <br /> 'The applicant t for ail r " rred in coons omplete drawin reverie side. <br /> !' Signed Titt�le M � - Date: <br /> F DEPART <br /> MEfVT USE ONLY <br /> Appli ion Accepted by Date r f Z Area <br /> I P or n by to /' in IInspection by • <br /> Add nal Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Se ices <br /> Environmental'Health Permit/Services <br /> t 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMtTTED CK 0 JECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EK 11.21(REV.1/K5) <0 / <br /> EH 11.36 r <br />