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APPLICATION 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City k46eL. <br /> Lot Size/Acreage / <br /> Owner's Name ass Phone V0 <br /> r <br /> Contractor t-`-`"_e:L­'Address Po J90 117-7 License No. /6 z3 73 Phone 66 6Z <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION SYSTEM REPAIR O OTHER O Monitoring Well O <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 /> 0 In strial O Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Pf Domestic/Private Cl Gravel Pack O Tracy Type of Casing_. Specifications (( __ <br /> I'1 Public 171 Other n Delta Depth of Grout.Seal Type of Grout 1 <br /> I I Irrigation / Approx. Depth I I Eastern Surface Seal In tailed by <br /> Repair Work Done W Type of Pump w� H.P. / State Work Done lcb <br /> Well Destruction O WWI Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) >� <br /> Installation will serve: Residence_ Commercial_ Other <br /> Numbs of living units: Numbs f bedrooms7 <br /> Character of soN 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: We Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Welldation Property Line <br /> SEEPAGE PITS 11 Depth tze Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 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 shalt not <br /> employ any perso manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the f wing:"I ce ify 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 California." <br /> The appy ant r aN r . C pi awing on r arse side. <br /> Signed Title:- Date <br /> 4V <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t J �+t Date s ,` % Area_2 1 <br /> Pit or Grout Inspection by Date Final Inspection by r G Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH JRECEIVED BY DATE+ PERMIT'No. <br /> • EM 14-11.21 ' 1 /21INEV.t/N51 P � <br /> EH Sre !J 13c2601 /REf /�`/3 3 , <br />