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APPLIKCAtION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 coelpliance with San Jolquin Count Ordinance No. 549 and 1 and the Rules and Regulations of San <br /> Joaquin County bl HeT <br /> rvi <br /> Y <br /> Job Address City Lot Size re e <br /> w <br /> ner's N d r P o11//ny�e <br /> on 'actor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT rl DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTAL SYSTEM REPAIR ❑ OTHER O Monitoring Well Ca <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public ("1 Other n Delta Depth of Grout Seat Type of Grout t\ <br /> gation _Approx.4Dt4hl Ea�ste�rnourface Senl Installed by`Repair Work Done U Type of Pumpv1kP. � Stats Work Done Sealing r <br /> WeH Destructan O WNI Oiame erDepth it&D�th <br /> h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI N I I REPAIRiADDITION I I DESTRUCTION I 1 INo 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 bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 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 luch manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the f wing:"I certify at in the performance of the work for which this permit is' sued, I shall employ persons subject to work n's mpensa- <br /> tion le Cal orale. <br /> The at call for ad in ction . Complete drawing o verse side. <br /> Sp Tit Date: <br /> (�' FOR DEPARTMENT USE ONLY <br /> Application Accepted by \ Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date �y 3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Per t/Services <br /> 445 N San Joaquin, P 2009, Stkn, CA 95201 <br /> FE AMOUNT DUE AMOUNT REMITTED K# CEIVE BY 0 TE PERMIT'N0. <br /> IN ,,/ �� <br /> . EH 13.24111EV.1/A 1 y w �/ <br /> EH 11.21 f (/ <br />