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> APPLICATION FOR PERMIT <br /> t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �� <br /> ENVIRONMENTAL HEALTH DIVISION r3 <br /> P O BOB 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR <br /> (Complete in Triplicate) �5CEIVED <br /> A " <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork a:fd dabedThis <br /> application is made in compliance vith San Joaquin County Ordinance Ho. 544 and 1862 and the Rules add 1ge ,404fa Ban <br /> Joaquin County Public Health Services. ENVIR0N1Vlb'NJ'AL HEALTH <br /> Job Address-?& i� ""`�� City Lot Size/APE1,17 in <br /> Owner's Name UH > �-L— Address��°7� �� 1/L . — Phona� <br /> Contractor "�`""'����� Address4&! -C.k License No& Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES = DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL . PROBLEM AREA __CONSTRUCTION SPECIFICATIONS <br /> fl Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> CJ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public I') Other p Delta Depth of Grout Seal Type of Grout j <br /> CIrrigation w. Approx. Dept ❑ Eaarn Surface Seal Installed by <br /> fiepair Work Done 0- Type of Pump H.P 0 Z3 State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth v <br /> Depth Filler Material i Depth' ! <br /> TYPE OF SEPTIC WORK: NEW-INSTALLATION Ll REPAIRIAODITION 0 DESTRUCTION.CI (No_septic.system permitted it public sewer is <br /> T - — - - 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 0 Type/Mfg Capacity No. Compartments <br /> w <br /> PKG. TREATMENT PLT. L1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line <br /> s <br /> i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line I <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 cartifies 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 /> cartifies 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• j <br /> tion laws of California." <br /> The applicant ust c9 for all requir d inspection Complete drawing on reverse side. J <br /> Signed � _-_ -- �'mttle: � — Date: <br /> t <br /> FOR DEPARTMV_ENT USE ONLY <br /> � <br /> Application Accepted by Date ;2`2j` � Area a <br /> Plt or Grout Inspection by Date Final Inspection by Data k1 <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 2008, STOCKTON, CA 85201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASA RECEIVED BY DATE PERMIT NO. <br /> r fH 1324tREV.1/n5� <br /> f :4•.26 V� ..0 �. •�.i` C11- IC I <br /> i <br />