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APPLICATION FOR PERMIT <br /> af <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> pR JJ .XpTRt S IL YEAR rR_ ISSUP- <br /> (Complete in Triplicate) <br /> Application is hereby Slade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in conplianee with San Joaquin County Ordinance No. 549 and 2 and the Rules Lad Regulations of San <br /> Joaquin County Public Health Service ` <br /> re � City Il�� L Lot Size/Acreage <br /> Job Address <br /> t <br /> Owner's Name 4A- Address Phone <br /> Contractor <br /> Addres 8 License No Phone o2 <br /> of <br /> TYPE OF WELLIPUMP: NEW WELL © WELL REPLACEMENT Q M <br /> DESTRUCTION ❑ Out Monitoring Well <br /> Service Well C1 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR OTHER O <br /> 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 /> 0 Industrial 0 Open Bottom 0 Manteca Did. of Well Excavation Dia. of Well Casing <br /> Domestic/Private O Gravel Pack 0 Tracy Type of Casing Spetii}icattons <br /> M Public fa Other ClDelta Depth of Grout Seal Typo.of Grout <br /> 4 <br /> Cl Irrigation Approx. Oep Eastern Surface Seal Installed Iby <br /> Repair Work Done La( Type of Pump H.P. _ — State Work Dora <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth "V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D AEPAIR/ADOITiON M DESTRUCTION Cl INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wilt serve: Residence — Commercial_,,., Other s <br /> Number of living units: Number of bedrooms <br /> Character of &oil to a depth of 3 feet: Water table depth <br /> / s e <br /> SEPTIC TANK .❑ Type/Mfg Capacity No. Compsrtme1ts,. <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation. Property Line a,r <br /> LEACHING LINE L'1 No. & Length of lines Total length/sire : <br /> ��4 <br /> II FILTER BED C-I Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> W II Foundation Property Line <br /> SUMPS LI Distance to nearest: e <br /> DISPOSAL PONDS 0 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, 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 such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> eertilies 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 comps a <br /> tion laws of California." <br /> r <br /> The applic us all for all required ' ti Co ate drawing on reverse side. <br /> Signed Title: ._._fS x=Date: <br /> FOWDEPARTMENT USE CNL1Y , <br /> Application Accepted by ADate _� —CP-- Ara, <br /> Pit or Grout Inspection by Date Final Inspection by Date SIU-6---to <br /> Additional Comments: - <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445.N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PEAMIT'NO. <br /> INFO }j5 . <br /> . E„ 13-24tR4 <br /> EV.I/R5) ,E # 9'0 -3-a P <br /> EM.4.26 I <br />