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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR <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 Compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic <br /> Jab Address ( Citetis�'°tL Size/Acreage <br /> Owner's Name Address Phone <br /> Contrac Addres License Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ / WELL REPLACEMENT f❑ DESTRUCTION C1 Out of Service Well [DPUMP INSTALLATION G SYSTEM REPAIR ;f OTHER ❑ Monitoring well C7 <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 /> n fndustrisi ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing f <br /> omestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications <br /> M Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation ��Approx, Depth 0 Eastern f Surface Seal Installed by <br /> Repair Work Done ftY Type of Pump _ H.P. � State Work Done a' <br /> Wall Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Piller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION M DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of moil to a depth of 3 feet Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, C7 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Wait 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, slate laws, and <br /> rules and regufations 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 II for all re uir ions. Complete drawing on reverse side. <br /> Signe _ Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �Z- Area <br /> Pit or Grout Inspection by Date Final Inspection b Data/ <br /> Additional Comments: <br /> Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O SO 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK /RECEIVED BY ATE PERMIT'NO. <br /> • EH 14'M <br /> iteEV.i n s� ' <br />