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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) 4683447 <br /> PEMIT EXPIRES 1 YEAR Et{?id_P&TE 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 Ban <br /> Joaquin County Public Health Services. <br /> � ' <br /> Job Address ��DZI Nr . City �r� - Lot Size/Acreage <br /> Owner's Name Address --., /, � f` - Phone <br /> Contractor ddress License No. .4�/ Phone <br /> TYPE OF WELL/PUMP: NEW WEL X WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALL.ATION/kr' SYSTEM REPAIR 0 OTHER O Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK AJI SEWER LINES DISPOSAL FLD.--- PROP. LINE —& � <br /> FOUNDATION 992/ AGRICULTURE WELL OTHER WELL -=~ PITS/SUMPS r~ ` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION_S <br /> Ff <br /> Cl Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private iravel Pack ❑ Tracy Type of Casing Specifications1>1 <br /> M Public 1"l Other ❑ Delia Depth of Grout Seal f Type of Grout <br /> M lni0ation R.;EOApprox. Depth ❑ Eastern Surface Seal Installed by .$ z� ez "T__ <br /> Repair Work Done 0 Type of Pump �_ H,P. C2 State Work Done _ <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material to Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 206 feel.l <br /> Installation will serve: Residence— Commercial r 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. 0 Method of Disposal <br /> Distance to nearest: Well Foundations Property Line s <br /> LEACHING LINE 0 No. & Length of lines Total length/size-- <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ _ a <br /> 1 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 comity 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 following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- r <br /> tion laws of California." <br /> The applicant rc I req tions. Complete drawing on reverse idet"1 <br /> Signed �'��~ Title: �- Data:4 / <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by / Date ^�� }} _ Area <br /> Pit or t Inspection by Date �� /�� Final Inspection by�r �e/ Date <br /> 60Additioonal Comments: �� � �'�"' ' '�- <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2000, STOCKTON, CA 85201 <br /> FEE <br /> INFO AMOUNTyDUE �`-AyMOUNT REMITTER SASH <br /> EH.4. RECEIVED BY DATE PERMIT NO, <br /> . EH 13•N26 trSEV.iIwai ��VV V /� ! i'� qQ ' l <br /> Li{/�� <br />