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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 /> PERMIT FIRES 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 Pub is Health anry s. <br /> k/ <br /> Address t�aL{ City <br /> Job � Lot Size/Acreage <br /> Owner's Name Address Phone <br /> Contract l � Ad ess Z � License a Nam' Phone <br /> TYPE OF WELL/PUMP: NEW WCLL O WELL REPLACEMENT ❑ DESTRUCTI O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well O <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 /> * Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> * Domestic/Private O Gravel Pack O Tracy Type of Casing_. Specifications ."tom <br /> 11 Public Cl Other Fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth v� ) <br /> Depth Tiller Material A Depth l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIONIIx No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soll to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments , <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Q No. ✓y Length of lines Total length/size <br /> FILTER BED O 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 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 laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature Certifle the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any son in such manner as to become bject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t fo ng: "1 certify that i tM perfor rice of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tionP <br /> ls."The acall or ad inspect' Complete drawing onr side. <br /> ffsig <br /> l/ <br /> Title: f\ Date: <br /> F DEPARTMENT USE ONLY <br /> < � t <br /> Application Accepted by04a.-ADate r Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 <br /> INFO AM�O�UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> . EM 14-41(IIIN.i 1.45 i n 5) (1 y z, Lim <br /> EH 1 �J (( ` O <br />