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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> pMWIT EXPIRES I YEAR PROM PATE- ISSUED <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 County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> kJob AddressVIL city.�� - Lot Size/A resge <br /> / r119e)' <br /> �( Owner's Name ddress <br /> et 1­� <br /> Ji/Contractor Add License No. Phone <br /> \TYPE OF WELL/PUMP'. NEW WELL 0 WELL REPLACEMENT 71 DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 ; <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 WEII PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> In Industrial ❑ Open Bottom ID Manteca Die. of Well Excavation Dia, o}Well Casing <br /> U Domestic/Private L1 Gravel Pack . O Tracy Type of Casing Specifications <br /> M Public 1-1 Other ❑ Delta Depth of Grout Seat Type of Grout _ --- <br /> CI Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> well.Destruction O Well Diameter Sealing Material b Depth <br /> Depth `Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION-0 DESTRUCTION;. (No septic system permitted if public sewer is <br /> available within 200 feat,) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ t` Method of Disposal <br /> Distance to nearest: Well,_____ Foundation Property Line <br /> th/size i <br /> LEACHING LINE Ll No. & Length of lines Total len 9 <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line + <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I hove 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 /> certifies the (lowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws C Iitor'I" <br /> The app cant ust call 11/all re I ad inspectio mpl a drawing on reverse side, <br /> �5igned Title: CilDate: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by a Data 3 ' Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N BAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTER AS RECEIVED BY DATE PERMIT N0. <br /> INFO <br />' • EN 17.24(REV.v h Sl :1 4 <br /> O9 <br /> t H -� <br /> E <br />