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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> E P 0 BOX 2009, STOCKTON, CA 95201 <br /> I <br /> PERMIT EXPIRES I YFAR FROM D TE <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 In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I Job Address E 5TQ <br /> � City. Lot Size/Acreage <br /> 5 <br /> Owner's Name Address ti" Phone <br /> Contractor Address f' License No. Phone <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service ifell 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Yell ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK 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 /> CI Industrial ❑ Open Bottom ,C7"Manteca Die. of Well Excavation Dia. of Well Casing <br /> C1 Domestic/Private ❑ Gravel Pack �L7 Trac_y�_w, ,jype of Casing_ Specifications <br /> Il Public Ci Other Fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> j Repair Work Done U Type of Pump H.P. State Work Done <br /> ' Well Destruction 0 Well Diameter" Sealing Material i Depth <br /> Depth Filler MiterialPefth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION (V DESTRUCTION 1 I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other o <br /> Number of living units: Number of bedrooms _ <br /> ` Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg L ' Capacity r7 <br /> PKG. TREATMENT PLT, No. Compartments fA� <br /> C3 . � Method of <br /> Distance to nearest: Well[1�fL*J Foundation _ Property Line <br /> i LEACHING LINE ❑ No. ✓4 Length of lines C\` <br /> Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation T Property Line <br /> SEEPAGE PITS 11 Depth Si:e Number a� <br /> SUMPS LI Distance to nearest:Wall Foundation�� Property Lina' " <br /> ISPOSAL PONDS ❑ / <br /> I hereby certify that I have prepared this application and that,the work will be done in accordance with San Joaquini.county ordinances, state laws, and <br /> i 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 or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> j The applicant all far ail r u' inspections. omplete drawing on averse side. ff�� <br /> Signed Title: O^ <br /> L E- Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> on Dots Aree2A If <br /> ,,, <br /> i' Pit or Grout Inspection by Date Final Inspection by r Dats3 <br /> Additional Comments.- <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, ox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK R CEIVED BY D € PERMIT'N0. <br /> INFO <br /> EH 14.78 EH 13•74INEV.r/n6I 0 // it <br /> • 0 i V <br />