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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERI[IT EXPIRES 1 YEAR FROM DATE ISSUED NO <br /> (Complete in Triplicate) 1t� <br /> - �� <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 Aq5, City Stv— Lot Size/Acreage <br /> Owner's Name Address Phone <br /> Contractor AddressC_L&y±CUh4se No. Phone s <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well 5 <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 /> Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I <br /> I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by { <br /> Repair Work Done U Type of Pum <br /> P H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material 0 Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTIONptic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: ResidpncsCommercial then <br /> Number of living units: _L/ Number of bedrooms <br /> Character Of"to a depth of 3 fast: Water table depth <br /> SEPTIC TANK. ❑ T <br /> yp./Mfg Capacity No. Compartments 7 <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. & Length of lines <br /> Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state <br /> rules and regulations of the San Joaquin County laws, and <br /> Homs 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 /> c ii the fo °ng: ertify that in the perform* a work for which this permit is issued, I shall em to <br /> tion C ornle." P Y Persons subject to workman's compensa <br /> applican call fo r omplete d wing on verse sips. <br /> Sig Title: 23 - 7 <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date ea q <br /> Ph or Grout Inspection by Date Final Inspection b Dat✓ <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 0 Box 2009, Stkn, CA 95201 <br /> AMOUNT DUE AMOUNT REMITTED CK <br /> �FEE <br /> NFO CASH RECEIVED BY DATE PERM17 N0. <br /> . EH 14.26(REV.�ins� � ^��� <br /> EH,..m � � r C� l oq 2-. 307 <br />