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5 i <br /> 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 /> 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 liar <br /> Joaquin County Public Health Services. <br /> oZ <br /> Job Address /tel �/ City Lot Si -/Acreage f <br /> Owner's Name ■ 1 u ''+� r� A�s a € Phone ` Z <br /> Contractor ?Address f License No.�'2 _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring well C7 <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 /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> J*omesticlPrivate Ll Gravel Pack C] Tracy Type of Casing Specifications <br /> FI Public n Other F1 Delta Depth of Grout Seal type of Grout <br /> I I Irrigation jgqppprox. Depth I I Eastern Surface Seel Installed by <br /> Repair Work Done LJ Type of Pump :Sjrj H.P. State Work Done —DD '9 <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (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 <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. b Length of lines Total length/size <br /> FILTER BED D Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundations Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hareby certify that I have prepared this application and that the work will be done in'sccoLrdance with San Joaquin county ordinances, state laws, and <br /> ruies 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 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 applica I r ns. Complete drawing on revers side.• # 1 <br /> Signed X — Title: Date: <br /> F DEPARTMENT USE ONLY r r <br /> Data . L- .__ gree 0 l I <br /> Application Accepted by nr --- <br /> Ph or Grout Inspectionby Date Final Inspection by Date <br /> Additional Comments: v� ""`�' Z 9Z-�9�� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services p <br /> 445 N San Joaquin, P 0 Boz 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED By DATE PERMIT-NO. <br /> INFO t(/ �( e��� CASH 1 7 ?2- <br /> EM. EK I]44(REV.1/#151 T 2 'I 5 .0 li 4 S t 0 " Ito / <br /> �(T�� �— . <br /> 44-m <br />