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y APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESTAL HEALTH <br /> P` 5 <br /> LA <br /> IVAI P 0 BOX1RONM2009, STOCKON, CA1SION 95201 <br /> v (209) 468-8 .3y'-© <br /> PERMIT EXPIRES 1 YEAR PROM DATE ISSUED <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 compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Sere pes. <br /> P <br /> g 'ize/Acreage <br /> Job Address �l^ " City ALJ <br /> Owner's Name Address hone / <br /> Contractor ddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL EPLACEMENT O DESTRUCTION 0 Out of Service Well O <br /> PUMP INSTALLATION O SY TEM REPAIR C1/ OTHER 0 Monitoring Well L� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WE L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR GT'ION SPECIFICATIONS ( _ <br /> Ll Industrial O Open Bottom O Manteca Dia. of WI <br /> Excavation Dia. of Well Casing w <br /> U Domestic/Private Cl Gravel Pack 0 Tracy Type Casin Specifications <br /> M Public I:1 Other O Delta Depfh of Grout eat Type of Grout <br /> 0 Irrigation Approx. Depth ❑ Eastern rhea Soul Inst led by �J <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sea]�4 Material 1. Depth <br /> Depth Piller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTIONINo 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 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg f nc1Eao. Compartments <br /> PKG, TREATMENT PLT, Cl athod of Disposal <br /> Distance to nearest: 'Wblrtma oma hawst@)(Pired Wit &Teny Line <br /> LEACHING LINE ❑ No. & Length of lines _ Ysize <br /> FILTER BED CI Distance to nearest: ell" - '' IFo i 1vI' trtbpeny 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 cenifies 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 subcontracting signature <br /> cenifies 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 compenss- <br /> don laws of California." <br /> The applicant must r all required inspgctio Compl�drawinaon reverse side. <br /> Asigned <br /> X 0. Date: <br /> n FOPrPEPARTMENT USE ONLY (� i <br /> Application Accepted by �!'� • ` moo. Date -1 \ Area _ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: _ <br /> Applicant - Return all copiers to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. <br /> -71 EH 14.30 <br /> EH1J•14IREV.t/hS) r�tJ �`Z - Cl(� 1►"ti' eJ �+ l� 11' <br />