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1 <br /> �. APPLICATION FOR PERMIT <br /> , os40, , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> h 1 <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> P O SOX 2009, STOCKTON, CA 95201 MAY <br /> (209) 468--3447 <br /> 30 "111RONMENTAL <br /> nt:Ri IT EXPIRES 1 YEAR ? OM DATT ISSUII? <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 /> Jab Address _ �"Ps''" `r &�"j � City Lot Size/Acreage <br /> 4_ Address Phone <br /> Owner's Name <br /> A � <br /> ContractorAte Address License N36�" -Phone c� <br /> TYPE OF WELL/PUMP: NEW WELL d WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 9�-' OTHER 0 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 /> F1 Ind ;trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 7omestic/Private O Gravel Pack C3 Tracy Type of Casing Specifications <br /> ID Priblic Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> l ' <br /> C3 Irrigation ��Approx. Depth ❑ Eastern I Surface Seal Instailed by <br /> Repair Work Done 0 Type of Pump H.P. y— _— State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth Il <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION CI INo septic system permitted if public sewer is <br /> .. , available within 200 feet.) J <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: w Water table depth <br /> SEPTIC TANK ❑ Type/Mfg -� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line T <br /> LEACHING LINE Cl ^No.i Lengih of lines Total Length/size , <br /> FILTER BED n Distance to nearest: Well Foundation " Property Lina <br /> SEEPAGE PITS I I Depth Site Number <br /> SUMPS LI Distance to nearest, Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <br /> I 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 /> r rules and reguiations 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-." C'ontractor's hiring or sub-contracting signature <br /> certifies the following: "I comity 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 applicant must call lop all uired inspec ' s. Complete drawing on raver, e, / p <br /> Signed Title: Date: �`�^' ^! l <br /> OR DEPARTMENT USE ONLY <br /> {{ Application Accepted by Dais Area <br /> f' Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOK 2009, STOCKTON, CA 95201 <br /> JX[.AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> �j C CASH <br /> -'Em 13.24IREV.1/N51 5�� @/Lj� <br /> EH—36 <br />