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APPLICATION FOR PERMIT <br /> °I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 t <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> rEEI[IT ! <br /> IRES 1 YE FR M D TE SU <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 costpliance with San Joaquin-county Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public HealthQ So <br /> A Ok,04r�f <br /> Cityf�- Lot Size/Acreage <br /> Job Address <br /> Owner's Name <br /> U Address Phone <br /> C S' �censeNo. Phone <br /> Contractor ddressWELL RE LACEMEN7 ClESTRUCTION; Out of Service Well Ll <br /> TYPE OF WELL/PUMP: NEW WELL 17 t4onitoring Well 0 <br /> OTHER j <br /> PUMP INSTALLATION C SYSTEM REPAIR D K Cs:•e o. <br /> SEWER LINES= DISPOSAL FLO. PROP. LINE <br /> DISTANCE 70 NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS _ (� <br /> FOUNDATION ��.�- AGRICULTURE WELL{ -- p � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> 0 Industrial O Open Bottom Q4iantec, Dia. of Well Excavation <br /> Type of Casing__ Specifications <br /> Cl Domestic/Pri ` ❑ Gravel Pack n Tracy Type of Grout <br /> VII Public/ I Cl Other n Delta Depth of Grout Seal <br /> zs <br /> 1.1 Irrigation ____Approx. Depth I I Eastern Surface Sal Installed by <br /> H.P. State Prk o e 77 <br /> Repair Wor one L7 Type of Pump �� Sealing Material i Depth, <br /> Well Destruction X Well Diameter: _ Tiller Material i Depth <br /> Depth a <br /> TYPE OF SEPTIC WORK: NEW ifdSTALLATION l 1 REPAIRIADDITION I I DESTRUCTION,11 sNailabperwithin 200 leet�jed if public Nawar is <br /> Installation will senro: Residence Commercial— Other + <br /> Number of living units. Number of bedrooms ;.r ' Water table depth <br /> Character of soN to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK. [3Type/Mfg . Capacity - <br /> Method of Disposal +� <br /> PKG. TREATMENT PLT.❑ fI <br /> Foundation ' Property Line <br /> Distance to nearest: Wells <br /> ' 5 ' <br /> Total length/size <br /> LEACHING LINE L1No. E Length of lines <br /> FILTER BED ❑ Distance to nearest; Well Foundation S Property Line <br /> SEEPAGE PITS 14 Depth f Sue Number <br /> SUMPS Ll Distance to nearest: Well -Foundation Property Line <br /> { DISPOSAL PONDS -❑ it -laws, <br /> f 1 hereby certify that I have prepared this application and that the work will be,done in acpordance with San Joaquin cotirity oitlinanees;'ateta'taws;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 wch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies the folowing;,fl.cerlify.thot in the performance of the work for which this permit is issued, I shall employ persons subject to workman's companse <br /> ` cion laws of Califorals." <br /> The applic all or ell lred 'nspsctions. Complete drawing on rete side �^ <br /> f Title: _ Date: <br /> Signed <br /> r FOR DEPARTMENT USE ONLY <br /> ' Date Area <br /> A Accepted by " _ <br /> 'l apection by <br /> Date Final Inspection b Date <br /> P. <br /> Grout or <br /> ddhkmal Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> I Environmental Health Permit/services <br /> 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> CK RECEIVED BY DATE PERMII'NO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> ®a <br /> . 11 <br /> EK 13.24(RM+/nal /° �� ( - <br /> EH 14.26 C� <br />