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es' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 4381 P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 4683447 <br /> e� v►•e �qr, L, / YEAR PHOM DATEISSUED <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 COWliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address l t dc- 40 L City P� Lot Size/Acreage <br /> Owner's Name Address r Phone <br /> ContractorAddress License No. Phone — <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION Ci SYSTEM REPAIR gUe 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 /> flIndustrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> A Domestic/Private 0 Gravel Pack El Tracy Type of Casing Specifications ^-y <br /> 0 Public i-1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> GI lrrigation — Approx, Depth ❑ Eastern Surf, aI Installed by <br /> Repair Work Done �5 Type of Pump H.P. _ State Work Don - <br /> Well Destruction 0 Well Diameter Scaling Materi i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION13 REPAIR/ADDITION M DESTRUCTION M INo septic system permitted if public sewer is <br /> available within 200 feel.) <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 f" <br /> SEPTIC TANK 0 T /Mf <br /> 1� g Capacity_.__ ..._ No. Compartments <br /> PKG, TREATMENT PLT, Cl Method of Disposal <br /> Distance to nearest: Well Foundation Properly Line �^} <br /> LEACHING LINE 0 No. & Length of lines „•„ Total length/size �J <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation __ Property Line <br /> DISPOSAL PONDS 0 <br /> 1 hereby certify that I have prepared this application and that the work with 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 perlorrnance 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, i shall employ persons subject to workm 's c pensa- <br /> tion laws of California," an <br /> The a ant must c for all required in tic, ve <br /> ns. C plate drawing on r rse side. <br /> Signed �-- �--- <br /> Title: Date:IF 10, <br /> l <br /> 72,F=ARTI�MENT USE ONLY <br /> Application Accepted by OD ItA, / Date T- Area <br /> Pit or Grout Inspection by Date Final Inspection by Date y <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES T <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX Zoog, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO ITS} CASH RECEIVED <br /> ECEIVED E3Y DATE PERMIT NO. <br /> • Ekl3.2AIREY.t?hSl <br /> ER•.�.1s f��L.Irl 1V1�+ri`` D <br />