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APPLICATION FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR PM DATE I UMM <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 cocipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ,Job Address � City t Size/Acreage <br /> Owner's Name �- Address Phone <br /> Contra- Addrea License N ho <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n ESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring well 17 <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 /> 11 In Ial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> M Public 1-1 Other p Delta Depth of Grout Seal Type of Grout <br /> CI frngation Approx. Depth 9 Eastern Surface Said Installed by <br /> Repair Work Done Type of Pump dayelc= H.P. _6S--0 State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE.OF SEPTIC WORK NEW INSTALLATION 4 RCPAIR/ADOITI )N Ll, OE$TRUCTION OL.,INoseptic":sysiem perry ilMed of pilblic sewer is <br /> x„ q y *a"^gvailable wuttrr♦2001 eat.I <br /> Installation will serve: Residence_. Commerctel `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 ❑ Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. fi Length of lines __ Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Lt Distance to nearest: Well foundationProperty Lin <br /> DISPOSAL PONDS ❑ e <br /> A�MgNr <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ortrce , Rand <br /> rules and regulations of the San Joaquin County �J�I <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which t r 't rs I su d,9f II not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hit' r ure <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ pertbEriurk► s �a• <br /> tion laws of California." MtN ' J <br /> The applicant must c r alt required i poplions. Complete drawing on rever ide. � ���`�� <br /> Signed Title: — Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by7Q <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O B 009, STOCKTON, CA 86201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED K ECEIVED BY I ATE PERMIT NO, <br /> 1H 122 iRtY.iirSl <br /> EH 14.25 <br />