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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH <br /> P O BOX 2009s STOCKTON, CA195261. <br /> (209) 468-3447 <br /> Y R <br /> (Complete in Triplicate) <br /> Application is hereby made to San Josquln County for a Permit to construct and/or insiall the work herein described. This <br /> application Se made In eath Sgence with <br /> uia County Public Heallth San Joaquin Co ty Ordinance No. 549 and 1862 had the Rules and Regulations of Ban <br /> r cea. <br /> Job Address <br /> City of Size/Acreage <br /> Owner's Nam ddress <br /> A Phon�3 <br /> C ntracior <br /> ass. License Nb. <br /> TYPE OF W LL/PUMP: NEW WELL ❑ Phone ' <br /> W LL REPLACEMENT [ 1 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR C1 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: 'SEPTIC TANK � SEWER LINES C7 <br /> FOUNDATIOfJ DISPOSAL FLD.�, PROP. LINE <br /> AGRICULTURE WELL OTHER WELL"— PITS/SUMPS <br /> INTENDED USE TYPE OF-WELT. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industria! ETD pen Bottom ❑ Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> U 1) <br /> Domestic/ 0 Gravel Pack 0 Tracy' T <br /> ❑ Public Type of Casing Specifications <br /> C] Other ❑ pelta Depth of Grout Seal - "' <br /> CJ Irrigation __,.gpprpx, Depth Type of Grout { <br /> Rapair Wprk pone {] T P d Eastern Surface Seal Installed b <br /> YPe of Pum <br /> Wall Destruction 0 Well Diameter Sealing Material i Depth State�:N k <br /> Depth.-- - Filler Naterial i Depth G <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION Li DESTRU <br /> ON CI fNo septic system permitted if Commercial public sewer is <br /> Installation will serve: Residence y._.._ Other evailabfa within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of Boli to a depth of 3 feet: <br /> SEPTIC TANK p Type/Mfg Water table depth— <br /> PKG. <br /> e th <br /> PKG. <br /> 1 , <br /> TREATMENT PLT, 0 Capacity— �` No. Compartments <br /> Distance to nearest: ! Method of Disposal <br /> Foundation _ �� Property Line <br /> LEACHING LINE Cl NO..& Length of lines } <br /> FILTER BED [1 Distance to nearest; iI <br /> Found -Total lenkh/sire <br /> - <br /> Foundation � Prc3perty�Line <br /> SEEPAGE PITS I I Depth <br /> SUMPS Sira Number. <br /> ---�------�-„,�Ll_-Riatanca-to-near .- �Wbil�-•-----w� � "• _..__ <br /> DISPOSAL PONDS ❑ Foundatio Propert;�tine a <br /> I hereby certify 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 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 laws of California,” Contractor's hiring or sub-contracting signature <br /> cercilles the following;aifi "I certify that in the Performance of the work far which this permit is issued, I shall employ: <br /> tion laws of California." p <br /> p y persons subject so workman's compensa• <br /> The applicant must call for ail required Inspections. Complete drawing on reverse side, <br /> Signe <br /> Title: <br /> Date: <br /> R DEPARTMENT U NLY <br /> Application Accepted by <br /> � Z- a � <br /> Pit or Grout Inspection by Date -�.� A <br /> Date Final Inspection by <br /> Additional Comments: Oats <br /> Applicant - Return all capias to:, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IF <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> ffN <br /> E AMOUNT DUE <br /> O A OUNT AEMtT tED CK RECEIVED BY <br /> CASH DATE PERMIT'NO. <br /> EH1�•Z�fRli4.�insr 0 0 <br /> e►r;�•m K^• plc i�,v q Y <br /> A <br />