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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVYSION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> .. AT21RYiT EMIRES I YEAR I� OIi DgTI �SSUBD <br /> (Complete in Triplicate) <br /> for a permit to construct end/or install the work herein described. This <br /> Application is hereby made to San Joaquin County <br /> application is made in ecupliance with San Joaquin.County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i' <br /> Lot Size/Acreage <br /> Job Address <br /> ' sS City - <br /> _ l7 <br /> AddressPhone <br /> �J <br /> Owriai s.Na - y 'r' •, <br /> - - f v <br /> TYPE OF WELL/PUMP: .NEW WELL 0 t WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well E-1 <br /> w k-A"' SYSTEM REPAIR 0 OTHER ❑ Monitoring Well U <br /> g PUMP INSTALLATION ❑ <br /> j DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK .__.� _ SEWER LINES <br /> t FOUNDATI N AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 71 <br /> iNTENOED USE TYPE}or- WELL PROBLEMAREA CONSTRUCTION 5PECIfICATlONS <br /> n Industrial C3Open Bottom C] Manteci Dia of well Eiccavation� Dia of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy. Type of Casing - Specifications <br /> M Public f-1 Other ❑ Delta Depth of Grout Seal:"' a Type of Grout (] <br /> . �. ley <br /> _ Approx. <br /> ❑ Eastern =I Surface Seat Installed by <br /> Ci Irripalion 1 <br /> Repai'r INfirk Done-U-- TV"--of-P06P :,.�+-�= H.P. ' <br /> State Work Done — <br /> ' <br /> ' I Sealing Miterial i Depth- <br /> well DAsffudtion ❑ ".Well Oiaiingter r t <br /> } <br /> � ...�, , <br /> Depth I i Filler Material i Depth <br /> 7 <br /> ' 'TYavailable within 200 leet.l <br /> PE'OF'SEPTIC'WORK: NEW INSTALLXT.ION. REPAIR/ADDITION 0 DESTRUCTION CI INo septic system permitted if public sewer is <br /> i i �rt i •.3 '`r <br /> 1 Mt7 �L � t ' <br /> Installation will serve: Residence Co merciaf_ Othet c:.-------- -� JT <br /> j2 4 i <br /> ;�--�--- Number of living units: Ntftfiber of bedrooms r„„ <br /> 'r <br /> Character of soil to a depth of 3�feet:: f` Water table depth <br /> SEPTIC TANK. Type/Mfq `--i t Capacity No. Compartments <br /> PKG. TREATMENT PLT,0 4 F < ¢ Method of Disposal <br /> IFF ; <br /> 'Distance to nearest: Wellt14® Foundation l0_ PropertysLine �y <br /> LEACHING LINENo,-fs Length of lines I �Tota'Ienat�/size' <br /> FILTER BED 0 Distance to nearest: Watt `~ foundation - Property Line <br /> { I i ! t / ';. , 11 <br /> ! SEEPAGE PITS 11 'Depth"'# Sizej F_ a Number <br /> SUMPS LI Vstance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and tha( the work will be done'imaccordance vvith`San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> ' Home owner or licensed agent's signature cemifies 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 ati to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> canifles the following: "I certify that inAhe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of Californla." <br /> The applicant must call for required ' spe tions, Comp a drawing on reverse side, <br /> ' Signed t Title Date: <br /> 1 FOR DEPARTMENT USE;-ONLY ` <br /> Application Accepted by ! .5 Date Area <br /> Pit or Grout Inspection by !t Date Final. ln:pe ion by Date <br /> Additional Comments: <br /> Applicant - Return all copies tor SAN JOAQUIN COUNTY PUBLIC, <br /> H TH SERVICES <br /> { ENVIRONMENTAL REALTN DIVISION'PERMIT/SERVICES <br /> Ilk' 445 N SAN JOAQbIN, P O 130X'�2009, STOCKTON, CA 95201 <br /> I - ' <br /> FEE AMOUNT DUE ' AMOUNT REMITTED Cx' RECEIVED BY DATE PERMIT NO. � <br /> INFO <br /> EK 111.26 <br /> , <br />