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APPLICATION FOR PERMIT r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r} qA ENVIRONMENTAL HEALTH DIVISION <br /> L� L� P O BOX 2009, STOCKTON, CA 95201 N D�j <br /> 111/('�k� <br /> (209) 468-a44734-2-0 N 0 <br /> PERMIT EX IBES 1 YEAR PROM DATE ISSUED <br /> i, <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 Iin compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Publ c Health Services. a V 'd_ <br /> 1 Job Address <br /> City Size/Acreage <br /> X Owner's No ddress <br /> Phon� <br /> Contract Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well O <br /> PU P INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER onitoring Well <br /> DISTANCE TO NEAREST: SEPTI K SEWER LINES DISPOSAL F PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OT ELL PITS/SUMPS .._ <br /> INTENDED USE TYPE OF WELL P M AREA CONSTRU SPECIFICATIONS <br /> M Industrial O Open Bottom ❑ Manteca Di ell Excavation Dia. of Well Casing r A <br /> U Domestic/Private O Gravel Pack ❑ Tracy of Casing- <br /> 00 <br /> asing Specifications <br /> Cl Public I'1 Other O D Depth o t Seal Type of Grout - <br /> G Irrigation Approx. Dept Eastern Surface Seal Insta by <br /> Repair Work Done U Type of P H.P. St ork Done _ <br /> Well Destruction O W lameter Sealing Material 4 Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION (No septic <br /> lable syst m resorted if public sewer is <br /> avaInstallation 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, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS O <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 Celif nis." <br /> The app' pt call Jor all require ns ns. Co ete drawing on reverse side. ^� <br /> �(Signed Title: �h��-= - Date: -' L <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area C� <br /> Pit or Grout Inspection by Date Final Inspection by Dat* Z <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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> . EH 13•71IREV.I/hs1 <br /> EN:!•26 <br />