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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Y ENVIRONMENTAL HEALTH DIVISION <br /> ' 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ` E11RM T EXPIRESI y FR 1[ "DATE SU <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the xork herein described. This <br /> application is made in cosrpliance with San Joag4V County Orth ance Ho. 544 and 2862 the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> �1/ I <br /> Job Address ; City Lot Size/Acreage <br /> Owner's Name, ' <br /> Address Q. w L <br /> -Phone - <br /> Contractor <br /> L <br /> ddress' dch No. Phone " <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANKS <br /> EWE LINES �� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation <br /> El Domestic/Private ❑ Gravel Pack ❑ Trac Dia. of Well Casing <br /> Y Type of Casing_ <br /> 1.1 Public Specifications <br /> I:7 Other fl pairs Depth of Grout Seal w <br /> I I Irrigation A Type of Grout <br /> Approx. Depth I I Eastern Surface Seaf Installed by - <br /> 'Repair Work Done U Type of PumpH p <br /> Well Destruction ❑ Well Diameter Seali Stats Work Done <br /> ttg..Material i h <br /> Depth Filler Miterial i pth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR OtTION i DESTRUCTION I I INo septic system permitted it public sewer is. <br /> Installation will serve: Residence___- Commercial Other available within 200 loot.) t t <br /> Number of living units: Number of bedrooms 'F <br /> k } <br /> Character of soR to a depth of 3 feat: <br /> SEPTIC TANK. Water table depth rnr <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl ' 1 <br /> I Method of Disposal <br /> Distance to nearest: Well Foundation """` - - <br /> --�.� Property.Line f <br /> LEACHING LINE ❑ No. 8 Length of linea j <br /> FILTER BED Total length/size,= <br /> O. Distance to neatest. Wall Foundation fi <br /> I Property Lino <br /> SEEPAGE PITS 11 Depth t e ' <br /> q]SPOSAiL <br /> Number _.. � <br /> Cl Distance to nearest; Well Foundation `` <br /> PONDS ❑ - PrcpertY'-tirie .� <br /> Thereby certify that I have <br /> prepared this application and-thatthe work will be done in accordance with-San Joaquin county ordinances, state laws, and <br /> rules and regulations-of'the.-San Jgaquin Coitaty <br /> Home owner or I citnaed agent's signature certifies the following: "I certify that in the performance of ttie <br /> employ any person in such mariner as to become-subject to workman's compensation laws of Californiis permit s issued, I shall not <br /> a.' work for which thContractor'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, f shall employ persons subject to workman's compensa- <br /> tion iaws of California." <br /> The applicant rt ust calf for an regwFed inspections. Compl to drawing on reverse side. <br /> Signed C ..q 43 -3 Title: Date:R DEPARTMEf�T USE ONLY �. ,�Application AcceptedbyAreaPh or Grout Inspection by Date Final Inspectionby <br /> Additional Comments: <br /> t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 K San Joaquin, P O-BOx 2009,-Stkn, CA-85201 <br /> FEE LL"­--:%,� <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY <br /> DATE PERMIT'NO. <br />. EH 1174 IIIEY.i;n SY � e�„ <br /> fH 11•26 �— <br />