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e~ 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 /> YEAR 9ROM DATE ISSUED <br /> (Complete in Triplicate) <br /> C ` <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 CMWIiance vlth San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I <br /> Job Address City Lot Size/Acreage <br /> Owner's Name - Address �'� Phone <br /> Contract e �o 9`-'� ense 2— Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR fes' OTHER O Monitoring Well [7 <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 /> f_l tndust .a1 ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omastic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Q Public V1 Other ❑ Delta Depth of Grout Seat Type of Grout <br /> G lfrigation Approx. Depth C3 EasternSurface Soul Installed by <br /> Repair Work Done ellTypo of Pump,LJ H.P/ S t a t a Work D e <br /> Well Destruction O Welt Diameter Sealing Material 4 Depth <br /> Depth <br /> Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/AOOITION 0 DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 210 feet.) <br /> Installation will serve: Residence— Commercial-___ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth A" <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Gl Method of Disposal <br /> Distance to nearest; Well Foundation Property Line <br /> ---- --- C9 Y11�MlY11'- <br /> LEACHING LINE L-I No. & Length of lines Total length/size <br /> FILTER BED C-1 Distance to nearest: Well Foundation Property LZ, <br /> -fill OR 1992 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Wait Foundation Prop4stygI W rAl.14 S !l(;l S <br /> DISPOSAL PONDS ❑ ENVIRONMENTAL HEALTH C4uISIDN <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, Molla laws, and <br /> rules and regulations of the Sen 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 of sub-contracting signature <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- <br /> tion laws of California." <br /> The applicant m for all required i pections. Complete drawing on a erse side. <br /> Signed Title: Date:/P/ <br /> FO1i DEPARTMENT USE ONLY <br /> Application Accepted byData A2" Area <br /> Pit or Grout Inspection byDate Final Inspection by Date <br /> Additional Comments <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FE <br /> INFO M�OUk^ 7� 7T DUE tM/`a-ODUNT <br /> FH REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH i�•2a �}2Z.�Z 13.2 IRtY.ti sl [ r <br /> �/`- 7J- aQ Z �L+ QZ Z ` <br /> Fa <br /> { <br />