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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> R FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application'le hereby made,to San Joaquin County for a permit to construct and/or install the Work herein described. This <br /> application is made in couplianceivith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _� ` City Z_21 Lot Site/Acreage <br /> Rakp-r hr Owner's Name Address Phone <br /> ajContractor U + ddress �-� �Q'I� Afcense No �Phone <br /> TYPE OF WELL/PUMP: " - NEW WELL"❑. WELL REPLACEMENT ❑ "DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION ❑- -� SYSTEM REPAIR C7t OTHER 0 Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK'S ,` `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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrioation �_Approx;i epth ❑ Easterner. Surface-Seal Instatlad by J <br /> Repair Work Done LJ Type of Pump H.P. —State Work Done_ <br /> Wall Destruction O Well Diameter 3earling Material i Depth <br /> Depth 'Filler Naterial A Depth s <br /> TYPE OF SEPTIC WORK: NEW iNSTAiLATION 0 REPAIR/ADDITION DESTRUION G (No septic system permitted if public sewer is <br /> i - CTavailable within 200 feet.) <br /> Installation will serve: Residence A( Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character-of soil-to s depth of 3 feet: <br /> � Water table depth <br /> f SSEPNo. Compartments <br /> ment <br /> s <br /> rj� Typa/Mfg Capacity1� 6r <br /> PKG.TREATMENT PLT: ❑ ; {i J r Method of Disp�sal <br /> Distance to nearest: Well Foundation J Property Line. (� <br /> 1 <br /> LEACHING LINE No, 8 Leripth of lines `Q G1 Total length/size ~� <br /> { <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS iik Depth `) Size Numberh,l <br /> y SUMPS LI Distance to nearest: Well Foundation Property Line T �� <br /> DISPOSAL PONDS 0 ,I - <br /> I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and regulations of the San Joaquin{"County' <br /> Home owner or licensed agent's signature cenifies the following: "I cenify that in the performance of the work for which this permit is issued, I shall not r� <br /> employ any person in such manner as to tiecome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature\J <br /> certifies the following: "I cenify 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 requir trpopti4 Complete drawing on reverse side. <br /> Signed. Title: g 5777- " _ Date: <br /> �20REPARTMIIENT USE ONLY <br /> w <br /> i Application Accepted by Date Area C� <br /> Pit or Grout Inspection by �' Date Final Inspection byDate << 2-t. {iY <br /> +r ,� <br /> Additional Comments: - Cea!1/ — <br /> Applicant - Return all copies to:' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> FEE F INFO AMOUNT DUE '; AMOUNT REMi'F"tE0 CASH AECEIVED BY D�ATE 11?A-301 <br /> PERMI <br /> EH 13.24IREV,irnsi 1 J , ' ° �� `� 20 <br /> EN 14-M / lIV <br />