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APPLICATION FOR PERMIT <br /> el SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> - ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> t <br /> PERMIT EXPIRES 1 YEAR PROM 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. l <br /> Job Address �� a'� /Jt5�L� City�0C ",,'Lot Size/Acreage <br /> Owner's No Address�" ��U C1�-Address —ZoQ elf!4 Phone <br /> > l <br /> Contractor X � �4 Address �v�� ��/ r+��4�� ic�nse No.3� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L1 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O 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 /> CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> M Public I'1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> G Irrigation Approx, Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material 4 Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTIONRVINo 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 *oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Wolf Foundation Property Line <br /> SEEPAGE PITS 11 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 /> 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 laws of California." <br /> The applicant must call for all required inspections, Complete drawing on reverse side. <br /> Signed X Title oC� 44-.)4- PA- Date: '' b <br /> R <br /> DEPARTMENT USE ONLY �{ <br /> Application Accepted by (' r �� a,�,�,�c Date t '© Area <br /> Pit or Grout Inspection by Date Final Inspection by ,bJ 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, STOCKTON, CA 95201 <br /> FEE ACK 0 <br /> INFO UNT DUE AMOUNT REMITTED C-�A(SH RECEIVED BY DATE PERMIT NO. <br /> . EH 2�IItEV. <br /> A- <br /> EH 1�2* <br />