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„ter 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 /> P,M.IT ESBIRES 1_YEAR ROW-DATE ISHUBD_ <br /> (Complete in Triplicate) <br /> n <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 San <br /> Joaquin County Public Health Services. <br /> Job Address City ,Lot Size/Acreage <br /> Owner's Name AddPhone <br /> Contract r s Address >✓�/aA ' -'? License No.4�5 `-492 _Phon `� <br /> TYPE OF WELL/PUMP: NEW WELL-El . WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION D SYSTEM REPAIR OTHER ❑ Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Pubfie f 7 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CI Irrigation Appfac Depth ❑ Eastern p Surface Saul Installed by <br /> Repair Work Done Type of Pump �� H.P. >1�Z _ Stats Work Dona W f <br /> Well Destruction ❑ Well Diameter ��r+B Material i Depth i <br /> Depth Filler Material & Depth <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION! REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted it public sewer is _ <br /> available within 200 feet.) <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 t <br /> SEPTIC TANK ❑. Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal i <br /> Distance to nearest: Well 'F Foundation Property Line I <br /> LEACHING UNE Cl No. & Length of lines Total length/size <br /> FILTER BED Ll Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number r <br /> SUMPS L1 Distance to nearest:, Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify 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-cenifies--the-following;`"I-cartify that in-the perlormance of.the-work fat 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-contrecting_signature <br /> certifies the following; "i cenify that in the pariormance of theworkfor which this permit is-issued, I shall employ persons subject to workman's compensa• <br /> tion laws of California.” <br /> 4 _ <br /> The applican al for all require 'ins clions. Complete drawing o reverse side, <br /> Signed Title: Date: <br /> OR DEPARTMENT USE ONLY / J' <br /> Application.Accepted by Date ` Area� ^ <br /> Pit or Grout Inspection by Date Final Inspection by Date ealg� <br /> Additional Comments: <br /> Applicant - Return all copies to- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES — <br /> ENVIRONMENTAL HEALTH DIVISION PtRMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CA5H RK if ECEIVED BY DATE PERM17'N0. <br /> . EN 11"2I(REV, Hsi ��(t V _Y <br /> EM <br /> i <br />