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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. j 4 <br /> ~ t Size/Acreage r r <br /> Job Address City <br /> Owner's Name dress Phone <br /> Contractor s �g�ese No. Phone <br /> UIP Y�f <br /> TYPE OF WELL/PUMP: NEW WELLLO WELL REPLACEMENT ❑ f DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS e <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [l Domestic/Private O Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> Il Public Cl Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump .-R-P-. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth 1 <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTAL LATIOIJ 1RTADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence L 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 O Type/Mfg Capacity-T-Vi�.LdL No. Compartments <br /> PKG. TREATMENT PLT.O "� / Method of Disposal <br /> Distance to nearest: Well Foundation ` Property Line <br /> LEACHING LINE C1 No. 6 Length of lines Total length/size <br /> FILTER BED O Distancetonearest: Well Foundation!— Property Line <br /> SEEPAGE PITS I I Dept f/ i:e �, � ,,�Nu�mber <br /> SUMPS Distance to nearest: Well �' Foundation-��—� Property Line i C/d <br /> DISPOSAL PONDS O <br /> 1 hereby cenify that 1 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 /> Horne owner or licensed agent's signature cenifies 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 /> cenifies the following:"I cenify 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 applican I for �intions. m e drawing on re rse side. <br /> Signed4 Title: _ Date: <br /> 4// <br /> IFOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Ph or Grout Inspection by Date Final Inspection by Date �7 <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK 8 RECEIVED BY DATE PERMIT'NO. <br /> INFO ' CASH /Q <br /> . EH 17.74(REV. i x 6 1 �+7i(1 f �® �d �/� (� —(0 <br /> EH 14.75 5555! <br />