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E <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> { ENVIRONMENTAL HEALTH DIVISION <br />'E 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 1 P O BOX 2009, STOCKTON, CA 95201 <br /> i PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to SaaJoaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliazee with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County//Public Health Services. <br /> �`-7:�� t <br /> Job Address �_, !����'� City Lot Size/Acreage <br /> r <br /> Owner's Name 4. � � Address Phone <br /> Contractor �1 ��!/1 � . AddressLicense No. �O Phone <br /> TYPE Of WELL/PUMP: NEW WELL 11 'WELL REPLACEMENT n DESTRUCTION 0 Out of Service well L"1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> s <br /> FOUNDATION Tom.. AGRICULTURE WELL "'°"' OT'HER••WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS,'ti, <br /> 5 a <br /> E) Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casings <br /> C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> w <br /> 11 Public 1-1 Other ' F1 Delta Depth of Grout Seal Type,of Grout <br /> I I Irrigation —Approx. DD--epth I:I_Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump t# s H.P. <br /> State Work Done <br /> Well Destruction 0 Wall Diameter T Sealing Material & Depth g V�► <br />' Depth I biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION1' TRUCTION I 1 INo septic system permitted if public sewer is <br /> d_ available within 200 feel.}. <br /> Installation will serve: R dente!�comrnercia! Other <br /> . + <br /> Number of living units: Number of gums <br /> Character of soil to a (� # ' <br /> depth of 3 fest: Water table depth <br /> SEPTIC TANK. f�1pe7Mfg Capachyy142t2No. Compartments <br /> PKG. TREATMENT PLT. 0' � � _ _�4 Method of Disposal <br /> Distance to nearest: Well f Foundation Property Line <br /> LEACHING LINE' ❑ No, 8 Length of lines } ' Total length/size �> <br /> .FILTER BED 0 Distance to'nearest: Well x f Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll Distance tonearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 1 <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 Son Joaquin County <br /> Home owner or licensed a' <br /> a entnsture <br /> 1 g aig (certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 foNowing: "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 /> tlo of Coldornla." <br /> T applie at calf all quire in c�UqComplslo drawing an reverse si ' <br /> Siq _ Title: _ b —� Date: / <br /> FOR DEPARTMENT USE ONLY F <br /> Application Accepted by cR - - Date ��^ <br /> Area <br /> Pit or Grout Inspection by j 'Date Final Inspection b Date <br /> Additional Comments: <br /> A i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ; <br /> Environmental Health Permit/.Services <br /> 445 N San-Joaquin, P O Boa'2009, Stkn, CA 95201 <br /> FEE• INFO AMOUNT DUE I AMOUNT REMITTED CK A CASH RECEIVED BY DATE PfRMITNO. <br /> 37 <br />