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APPLICATION ( ( <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (. . S' <br /> ENVIRONMENTAL HEALTH DIVISION ��aL_J_ <br /> t� j ''1 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 10&U <br /> P O 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 /> xlob Address 4! City _ Lot Size/Acreage <br /> i tr _ <br /> Owner's Nam��/v/ V ��Lr � Address���� Phone <br /> Contractor (.�`���� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/S <br /> INTENDED USE TYPE OF WELL PRO AREA CONSTRUCTION SPECIFICATION <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of n Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Trac yp Casing__ Specifications <br /> I'I Public Cl Other Delta Depth of Gro al Type of Grout <br /> I I Irrigation _ ox. Depth I I Eastern Surface Seal Installs <br /> Repair Work Done 0 yps of Pump H.P. State <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is ` <br /> 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 y (� <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments �fy� <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �t <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 California." <br /> The app' ust call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: y Qf1'LQ'N Date: 7.2 q_g r <br /> R DEPARTMENT USE ONLY I <br /> Application Accepted by Date Area FD <br /> Pit or Grout Inspection by Date Final Inspection by ate <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 11 1 <br /> ASH RECEIVED BY DATE PERMIT'NO. <br /> . EH13.24(REV.1ixs)�� Af <br /> Lit OL1 "7.q.9' 1`9+— ]07 <br /> EH 14.20 """lll [—1 1 6 <br />