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t r 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 /> 2=11 EXPI IRS 1 . R <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 coisplisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> S� City Lot Size/Acreage <br /> Job Address <br /> t <br /> #j Address � "` c — Phone <br /> Owner's Name Y� <br /> Contractor <br /> ddress '53QLtcense NotA5�""" Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out.of Service Well ❑ <br /> OTHER ❑ Monitoring Well 0 <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> 040mestic/Private ❑ Gravel Pack 0 Tracy g <br /> 1:1Typs of Grout <br /> R Public 1-1 Other Delta Depth of Grout Sea!, <br /> CI Irriostion ��f/ _ Approx. Depth Q Eastern Surface Soul Installed by L <br /> Repair Work Dona LY-- of Pump. H•P•,�� State Work Done W <br /> Well Destruction D Well Diameter Sealing Material i Depth _ <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION fl REPAIRlAi]DIT10N Ll DESTRUCTION Cl (No septic system permitted if public sower is <br /> available within 200 feet.l <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. O Type/Mfg Capacity No. Compartrnants <br /> PKG.`TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest; Well Foundation Property Line <br /> LEACHING LINE L❑ No. 8 Length of fines Total length/siie <br /> FILTER BED n Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number"" <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line ` y <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 jaws, and <br /> L � <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 shalt 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 compensa. <br /> tion laws of California." <br /> Theapplicant must calf r all required ins actions. Complete drawing on r verse side. <br /> Signed x_, _ - Title: Date: 0 – <br /> OR DEPARTMENT USE ONLY l <br /> Application Accepted by Date r r Area Cw <br /> Pit or Grout inspection by Date Final Inspection by Date <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 0 BOX 2009, STOCKTON. CA 95201 <br /> CK 4 <br /> FEE AMOUNT DUE AMOUNT REMITrEO CASH RECEIVED 9Y DATE PERM17 tJO. <br /> A `{�� <br /> . EM 13-24 111EV.t�M 51 <br /> (�� f <br /> EH 114.26 fff <br />