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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BO% 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in coviliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Lot Size/Acreage <br /> Job Address ����`--� City <br /> WvAir's Name ddress Phon <br /> i .`Contractor Addres + License N4 �Pho <br /> TYPE OF WELL/PUMP: NEW WELL O WELL'REPLACEMENT V DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION.0. [,SYSTEM REPAIR ❑ ,- a40THER O Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL'"" PITS/SUMPS ._ <br /> INTENDED U5E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. <br /> 0 Industrial 0 Open Bottom ❑ Manteca r Dia.-of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> T Public Cl Other 0 Delta Depth of Grout Seal:' Type of Grout <br /> CI Irrigation ,WApproR+Depth C]Eastern Surface gaul7nsiailnd Dy ' <br /> r <br /> Repair Work Do e', U Type of Pump H.P. I State Work Done <br /> Welt Destruction O Well Diameter Sealing Material & Depth / <br /> {` Depth' ' Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION DESTRUCTION G iNo septic system permitted if public sewer is <br /> available within 200 feet.! <br /> 4 <br /> Installation will serve:, Residence.�L Commercial— Other- ^j, -� r, Ilk} <br /> Number of living units: 1— Number of bedrooms i r C> <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK _,� Type/Mfg —�__,. 1 ..Capacity-I�O___ No. Compartments ` <br /> .- <br /> = PKG. TREATMENT PLT:0 Method of Disposal <br /> 3 <br /> D'I+stance_to nearest,: -.fWel Foundation Property Line <br /> LEACHING LINEAlSTtI Na. 8 Length of lines Total length/size .! <br /> FILTER 13ED tn_ Distance to nearest. Well Foundation Property Line <br /> i <br /> i SEEPAGE PITS f�r46rl I bepth s Size Number <br /> t <br /> SUMPS _ LI Distance to nearest: Well Foundation' Property Lina `� f <br /> DfSPOSAL PONDS 0. . <br /> E <br /> + I hereby certify that t have prepared this application and that the work will be done in accordance with San Jo{ quin county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or.licensed agent's signature Certifies the following: "I certify that in the performance of the work or which this permit is issued, I shall not <br /> employ any person in such manner as to bftofn'e iubjeat to workmen's compensation laws of California," Contrpctor's hiring or sub-contracting signature <br /> certifies the following: "l 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." -,.y'.- I <br /> The appliCant must tail for all required i tions. Complete drawing on reverse side. i <br /> g Signed a Title: 2 Date: x <br /> €1M <br /> f FOR.DEPARTMENT-USE ONLY F <br /> q <br /> Application Accepted by I Date Q res ; <br /> t <br /> Pit or Grout Inspection by Date Final Inspection b oatg/ <br /> Additional Comma nta: <br /> Applicant - Return all cops a to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> n <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 { <br /> Y INFO FEE AMOUNT DUE AMOUNT REMITTED CASH REGHVED BY O'ATE PERMIT NO. <br /> L/.J+ i �y Q I <br /> . EH 13-24 INEV.1/N 51 L ,{ o qU-� -O <br />