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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> r' (209) 468-3447 <br /> \�E I PERMIT EXPIRES 1 YEAR rROM DATE ISS ED <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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. _� p� , ��f �, <br /> Job Address W7-0 � �; �7���^-�f Cit��1 06 Lot Size/Acreage <br /> x Owner's Nameh !? se-1 Address / 7 Q 2- �/� �rrr`1 7.27 <br /> Phon ® ---•� �' <br /> Contractor V,11,kc, ywAddress ,t C11111 1 License No. 3_0 Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT �❑.,/ DESTRUCTION ❑ Out of Service Well O <br /> pq <br /> PUMP INSTALLATION ❑ 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 /> \ M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications l A" <br /> M Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation -_.Approx. Depth_ Q,Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. . L State Work Done _ <br /> Well Destruction O Well Diameter- Sealing Material i Dept <br /> Depth Filler Material & Depth (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCT=Water <br /> (Nopermitted if public sewer is <br /> 0 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number bedrooms <br /> Character of toil to a depth of 3 feet: depth <br /> SEPTIC TANK O Type/Mfg Capaci No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well F dation_ Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size �" <br /> FILTER BED 0 Distance to nearest: We Foundation Property Line �_ <br /> SEEPAGE PITS 11 Depth Size Num <br /> SUMPS LI Distance t rest: Well Foundation Pro 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus or r quired i pections. Complete drawing on reverse side. <br /> Signed �' ► -` Title: Dater <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by r A.A& r •• a a Date �-� , Area <br /> Pit or Grout Inspection by Date Final Inspection by Te( �°j� C�r 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 O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNTREMITTEDCK <br /> CASH RECEIVED BY DATE aPERMIT NO. <br /> 00 <br />