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APPLICATION FOR PEPWIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PEMIT ESDI- YEAR LROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in ceagrliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> services. <br /> Job Addres �"�` Cit Lot Size/Acreage <br /> J/ 4�1 ) <br /> �� Owner's Nam .� 4 Address �d"���— Phone ;2 ` 6 Fl <br /> X)Contractor Address ^-' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE oring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO PROP. LINE <br /> FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF ROBLEM AREA TRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Dia. of Well Excavation x Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pac n Tracy 7yp sing Specifications <br /> ❑ Public 1- ❑ Delta Depth of Grout _ Type of Grout <br /> 0 IrriOation _..Approx. Depth n Eastern Surface Seal Installed by <br /> Repair W one LJ Type of Pump H.P. State Work Do <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Y Depth - Piller Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIR/ADDITION i=1 DESTRUCTIONY INo septic system permitted it public sewer is .. <br /> available within 200 feat.l <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 <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. $ Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 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 t llowing: "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 l s of C ifornis." <br /> Thepplicant ust call for I req d in Ctions. Complete drawing on reverse side. <br /> JSigned Title: YP Date: <br /> F R IEPART NT USE ONLY <br /> Application Accepted by Date �Aa <br /> Pit or Grout Inspection by Date Final inspection by Dat <br /> Additional Comments <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 995 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT t]t�Jgl() ( <br /> AMOUNT REMI�TTED CK REC/EIlVEO BY DATE PERM17'NO. <br /> EH 13-24 IREV.t�it 51 ,^�'0 i 1� 1 t, -3 -Q-1 1 T O <br /> EH 7i•$a l <br />