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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE {209}468-3420 t <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se ices. ti <br /> City.. . of Size/Acreage <br /> Job Address <br /> Owner's Name <br /> ss� Phone <br /> Contractor Address zNo /6ePhone <br /> TYPE OF WELL/P NEW WELL ❑ WELL REPLACEMENT ❑ f DESTRUCTION ❑ out of Service Well D <br /> PUMP If+i5TALLATiON ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ;r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom (D Manteca Dia. of Well Excavation _ Dia. of Well Casing ` <br /> Type of Casing- <br /> Il <br /> asin Specifications <br /> 9 <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy - <br /> I'I Public <br /> 1-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —Approx. Depth I I Eastern Surface Sea! Installed by <br /> Repair Work Done L3 Type of Pump H.P. State W6rk Done <br /> Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter <br /> Filler Material_! 'th <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION IV DESTRUCTION TA.lNo septic system permitted if public sewer is { <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: L— Number of bedrooms—v:::; ! <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg f Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ 1> Method of Disposal <br /> Distance to nearest: Wel! ll r,d tion Property Line n <br /> LEACHING LINE ❑ No. & LEnearest: <br /> Tota! length/sixe (� <br /> FILTER BED C l DistancWell Foundation Property Line <br /> SEEPAGE PITS 1.1 DepthSire Number <br /> SUMPS LI Distancell Fou ation Property Line <br /> DISPOSAL PONDS ❑ <br /> i hereby certify that I have prepared this application and that the work will be done in cordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Josquin 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." t <br /> The applicantst foEallequi paetions. Comp to drawing on reverse side. -3/C;?3 <br /> , <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area •- <br /> Pit or Grout Inspection by Date Final Inspection by Date 3 Yl'_ - <br /> j 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 2409, Stkn, CA 95201 <br /> KI <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. <br /> INFO <br /> + EK 13-24 IRM t'.851 � I Y ` LZ <br /> ��z3a lq3- OWr <br /> EH 14.26 - <br /> I <br />