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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) 468--3447 <br /> Y RATE <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���a'nc a No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �' O' <br /> C) F- j City fi/ Lot Size/Acreage <br /> Job Address <br /> Owner's Name <br /> O/C Address Phone <br /> Contractor <br /> •✓ Address License No. Phone <br /> TYPE OF WELLlP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well <br /> INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well L7 <br /> PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC — SEWER LINES — DISPOSAL FLO. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR M AREA .-TRUCTION SPECIFICATIONS Dia. of Well Casing <br /> M industrial Cl Open Bottom ❑ Ma Die. of Well Excavation <br /> of."Casing - Specifications - <br /> k U Domestic/Private Cl Gravel Pack Tracy. e Type of Grout <br /> C1 Public 1-1 Other ❑ Delta Depth rout Seal <br /> C}-Irrigation .�. Approx. Depth 0 Eastern Surface Seul Ilad by <br /> Repair Work Done Type of Pump H,P, <br /> State Work Done <br /> Sealing Material & Depth <br /> M Well Destruction O Well Diameter Filler Material i Depth <br /> Depth <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION Cl DESTRUCTION Ci available within 20(No septic system 0 feetlt�ed if public sewer is <br /> Installation will serve: Residence.__)M, 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- Type/Mfg r?k Capacity / No. Compartments <br /> ' PKG. TREATMENT PLT:Cl . , Method of Disposal <br /> r + l <br /> Distance to nearest: Well [ Foundation. Property Line- <br /> 4 <br /> �r <br /> LEACHING LINE � No. & Length of lines Total length/size <br /> FILTER BED !n Distance to nearest; Welt 2 Foundation Property Line <br /> SEEPAGE PITS I I Depth 5iis e Number <br /> SUMPS U Distance to nearest: Well� Foundation s Property Line <br /> DISPOSAL PONDS ❑ <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 taws, and <br /> rules and regulations of the San Joaquin County <br /> rtify that in the performance of the work for which this permit is issued, t shall not <br /> Home owner or licensed agent's signature certifies the following: "I ca <br /> employ any person in such maDpor as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "l y t i the performance of the work for which this permit is issued. I shall employ persons subject to workman's compensa- <br /> tion law's of Calif <br /> The ap nt must call for uired ' Pions. Complete drawing on reverse side. C� <br /> Signed Title: Data: <br /> FOR DEPARTMENT USE ONLY <br /> ` .gJ��,,.c�.,• . — ._. <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by �� Date t f <br /> Additional Comments: <br /> Applicant - Return all copies to: TH SERVICES <br /> ENVIRONMENTALCOUNTY JOAQUIN PUBLIC <br /> HEALTHDIVISIONLPERHIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 05201 <br /> FE£ CK RECEIVED BY DATE PERMIT'NO• <br /> INFO AMOUNT RtJE AMOUNT REMIT(EO gCASH <br /> . EH 13.24 MEV. n Sl O� - r t (] `� � <br /> ZI <br /> EH°x•26 <br /> t <br />