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' APPLICATION FOR PERMIT n <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONW&NTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95202 <br /> PERMIT E%PIRES I YEAg FROM D TE ISSU.Up <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 coalpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> Job Address `� G /G G. City �11r _ Lot Size/Acreage <br /> Owner's Name //LL d Address Phone 919(- <br /> Contractor C /�1� �sfLG . Address// +s /L 1e&trW1; <br /> TYPE OF WELL/PUMPLicense No.2d 1­6 SX Phone <br /> i : NEW WELL O�- <br /> r WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring bell <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia, of Well Casing <br /> Cl Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing �G <br /> - Specifications• <br /> 1'1 Public 1-1Other f-1Delta Depth of Grout Seat r� Type of Graut s <br /> I 1 irrigation �Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK7 NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION f I lNo Septic system permitted if public sower41 �: <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of 600 to a depth of 3 feet: Water table depth r• <br /> SEPTIC TANK. ❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> Method of Disposal � <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Pr <br /> DISPOSAL PONDS ❑ Ji <br /> rtY Line <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 /> rules and regulations 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." Contractor's hiring or sub-contracling signature <br /> certifies the following: 1 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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> T Title: <br /> Data: <br /> FOR DEPARTMENT USE ONLY � Z ., t�tn <br /> Application Accepted by p Date �" Area Off, ` <br /> Pit or Grout Inspection by Date f Z Final Inspection by W / q y <br /> }}� pate <br /> Additional Comments: �J 'tt✓ 12a (p�Q�( G� � Q j, O <br /> Applicant - Return all cop es to: San Joaqui County Public Health Servi es <br /> Environmental Health Permit/Services 1�+LYVy <br /> 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY /D/ATE PERMIT'NO. <br />. EH 17-31 1rtEV.I/n 5! <br /> EN 11.30 <br />