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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERI[IT 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 ccepliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address,. �+ � LI-- Cit Lot Size/Acreage <br /> Owner's Name adi Address d� � ��+ Phone <br /> Contractor Ai Address 07�, License No�SU Phone <br /> TYPE OF WELL U NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O out of Service well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR )11- 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 /> O Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications <br /> I'l Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth //�I IEastern Surface Seal Installed by <br /> Repair Work Done 16 Type of Pump .;JAL ' H✓P. I State W rk D no <br /> Well Destruction O Well Diameter Sealing Material • Depth <br /> Depth Filler Material i Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 v���,.ccritM"r <br /> Character of soN to a depth of 3 feet: PAMM" <br /> SEPTIC TANK O Type/Mfg Capacity— <br /> PKG. TREATMENT PLT.O oPe jyl�t�rQf�ist1MA! <br /> Distance to nearest: Well Foundation Pr x U <br /> sAN JOAOUIN CO NUNU Yr-a , <br /> LEACHING LINE L1 No. & Length of lines Total IeRJJIds HEALTFfSI�t' <br /> FILTER BED O Distance to nearest: Well Foundation EN* e <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 I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the San Joaquin County <br /> Homs 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 shell 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 applicant st all for quired inspections. Complete drawing on r arse side. <br /> Signed X� Title: Date: <br /> c <br /> T USE ONLY <br /> Application Accepted b � Date `� rea �� <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 O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y D TE PERT'N0. <br /> INFO MI ///� <br /> EMI 3-24(REV.r i M alK 429y <br /> EH 14.211 <br />