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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUM <br /> (Complete in Triplicate) <br /> Application In 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. f . <br /> Job Address a ` City !�- <br /> Lot Size/Acreage I �" e <br /> f Phone TT — <br /> Owner's Name <br /> Address �,1 <br /> � . �. ��� <br /> Conttactor� �n Address Li���No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION CI Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i ?1.DomesiWPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> j I'I Public 1.1 Other «."j—f Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ____.Approx. Dept�h �� I I Eastern Surface Seat Installed by <br /> Repair Work Done L7 Typo of Pump? H.P. _• - State Work one, ]a <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth f 4t <br /> > Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORKr�NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is \��l <br /> available within 200 feet.) <br /> Installation will serve: Rsifdence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sto a dipth of 3 feet: Water table d�ep <br /> oil �ath -F 6 <br /> :`PTIC TANK' . ❑ Type/Mfg Capacity No. Irh� <br /> fPKG. TREATMENT PLT.❑ futethpd.1e w <br />' Distance to nearest: Well Foundation PropertyZI9Lins�la 2 <br /> LEACHING LINE Cl No. 14 Length of linea Toial Iengflilsii i1 <br /> FILTER SED ❑ Distance to nearest: Well Foundation Prope'ftyjB-bJ%HEP"_ �f'�$'I�,�} <br /> ONMElvl AL i r- L� , ° <br /> !SEEPAGE BITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation 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 laws, and <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 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 /> t certifies the following: 1 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 /> The applicant mus all for an required ' c' ate drawing on reverse side. <br /> Signed Title: _ 4::e"es" Date: <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> rDate _2'�.�-� Area <br /> Application Accepted by <br /> q 3� <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 Services1�} <br /> t Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOiI T REMITTED CK ECEIVED BY D E PERMII'N0. <br /> t O CASH <br /> . EM 1E•24 IISEV.Ii n si <br /> EN 14.70 ✓ <br />