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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMHEALTH DIVISION <br /> P O BOX 2009, Stt TON, CA 95201 <br /> 1 (209) 468-3447 <br /> :PERMIT EXPIM I YEAR rROM. DATE law= <br /> ' (Complete in Triplicate) <br /> Application is hereby made;to San Joaquin County for a permit to construct and/or install the wok herein described. This t <br /> application is made in coV11ance with San Joaquin County Ordinance No. 544 and 1862 and the Rulelfttsd Regulations of San <br /> Joaquin County Public Health Services. t <br /> Job Address •� `3 3'� City Lot Size/Acreage <br /> Owner's Nam* t Address ?-y 3 /� --- Phone <br /> Contractor Address _ s• �� License No. Phone <br /> f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 0 <br /> z PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well U <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 /> n Industrial/ ❑ Open Bottom!',, C] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack- ❑ Tracy Type of Casing Specifications <br /> M Public I'1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Ci Irrivation�' _Approx, Depth D Eastern Surface Seal Installed by <br /> �. Repair Work Done 0 Type of Pump H.P. Slate Work Done'� .: <br /> Well Destruction ❑ Well Diameter I - sealing Material & Depth <br /> r. <br /> Depth f Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION Of DESTRUCTION M lNo septic system permitted it public sewer is <br /> r available within 00 feet.) <br /> Installation will serve: Residence^ Commercial I Other <br /> 1r <br /> Number of living units: Number of bedroomsiIM«/�s/ <br /> Character of soil to a depth of 3 feet: ? Water table depth i <br /> f SEPTIC TANK ❑ Type/Mfg l Capacity No. Compartments <br /> �.'PKG. TREATMENT PLT. ❑ Method of Disposal ' <br /> Distance to nearest: Well Foundation Property Line <br /> �. <br /> 14 \ <br /> LEACHING LINE ❑ No. & Lengthy of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> I <br /> a I <br /> ^' r.SEEPAGE PITS 11 Depth Size Y Number <br /> 4 SUMPS r Ll Distance to nearest: Well Foundation Property Line <br /> j r DISPOSAL PONDS ❑ I <br /> I hereby certify that I have prepared this application and that the woik will be done in accordance with San Joaquin county ordinances, state laws, and <br /> .rules and regulations of the San Joaquin d6unty ; <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 mariner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature N' <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- tt <br /> -tion laws of California." I I <br /> The applicant must call for all requited inspectio s. Complete drawing on r arse side. ;* <br /> Signed Date: <br /> - _ <br /> r FOR DEPARTMENT USE,ONLY•.• "^—k <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection b <br /> Additional Comments: 1 m I <br /> t <br /> il <br /> pplicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> # _ �Y. 44$,N.:SAN JOAQUIN, P O.,BOX 2009, STOCKTON, CA-85201- rye <br /> FEE AMOUNT DUE AMOUNT REMITTEO < RECOVEO BY DATE PERMIT'NO. <br /> INFO /y�J cCASH' ,�!},'� <br /> EHi'REV,i m p! ' // /�� /Fy1 /,N <br /> EH 114.2111 <br />