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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCSTW, CA 95201. <br /> (209) 468-3447 <br /> PFJtMIT R ?ROM DATE IUSUED <br /> (Complete in Triplicate) <br /> Application is hereby mnde,to San Joaquin County for a permit to construct and/or inatall 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 of Size/Acreage <br /> t <br /> Owner's Name Address Phone c <br /> Conlraa Addre AM License — Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELt REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well L1 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR �� OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Ind Ial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omsatic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public 1-1 Other ❑ Delta Depth of Grout Seat Type of Grout <br /> Ci Irrigation /,f—__Approx. Depth ❑ Eastern / Surface Seal Installed by <br /> Repair Work Done t3' Type of Pump �' H.P. �� State Work Done <br /> Well Destruction p Wall Diameter Sealing Material & Depth O� <br /> Depth Piller Material 6 Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo septic system permitted if public sewer is <br /> available within 200 feet.) —• <br /> installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedroomsxM' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity -- No. Compartments <br /> PKG, TREATMENT PLT. ❑ Meth#A%r <br /> Distance to nearest: Well Foundation Property Lin REeEIVE s <br /> LEACHING LINE " ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation PropertSAJgeJQ40U1W C U iY <br /> I Ti j 5EF�VIC,ES <br /> SEEPAGE PITS 11 Depth Size Number FUVIRONMENTAL HEAL!h L)I.'1 I <br /> UN <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that (have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and reguiations of the Sen 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 of 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 taws of California." <br /> The applicant mu all required ids etions. Complete drawing on erre side. <br /> Signed Title: Date: —a 3:122-- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <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, STUCXTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMI7'NO. <br /> . EN I3-741REV.rinse 0­0 1C_:>U7/1 6-r-) 92,2 9,96 <br /> EH 14.M <br /> -secs <br />