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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 /> P O BOX 2009, STOCKTON, CA 95201 <br /> i <br /> PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED � <br /> (Complete in Triplicate) <br /> i <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 aside in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Healt# 96rvices. <br /> Job Address City Lot Size/Acreage <br /> v Dwner's Name %t` � ddress Phone"593 <br /> + i <br /> i'll"Contractar rasa 1License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ f <br /> PUMP INSTALLATION ElSYSTEM REPAIR C1OTHER O Nonitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> I <br /> I'l Public Cl Other f"1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by ` <br /> Repair Work Done 0 Type of Pump H.P. Stats Work Done <br /> Nc , <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth ! <br /> Depth Filler Naterial i Depth � <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION [ I REPAIR/ADDITION l I DESTRUCTION INo septic system permitted if public sewer is �I <br /> available within 200 feet' <br /> installation rn: Residence Commercial_ Other j <br /> Number of living unite: Number of bedrooms <br /> Character of @oil to a depth of 3 mer table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I <br /> Distance to nearest:' Well n Property Line <br /> i <br /> LEACHING LINE 0 No. 8 Length of tines � Total !size � <br /> FILTER SED ❑ Distance to est: Well Foundation Property j <br /> i <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISP PONDS I-) <br /> araby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <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 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican mu call for all required inspections. Complete drawing on reverse side. <br /> XSigned Title: Date: ��� .� r <br /> R DEPARTMENT USE ONLY 1 <br /> Application Accepted by Date _9 9Z Area j <br /> Pit or Grout Inspection by Date Final Inspection <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, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOU REMITTED K RIRIVED BY D E PERMIT'NO. <br /> . EN 1124tREV.r i r sl Z :, <br /> t4. <br /> EN � ��Yff <br />