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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �'"� � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ZIMM-EXPIRES 1 YEAR SROM DATE_I 2UBp <br /> (Complete in Triplicate) NIP,' r <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 vith San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County/Public Health services. <br /> u (�./ /li/` Lot Size/Acreage <br /> City <br /> Job Address `r <br /> Owner's Name <br /> Address Phone � I <br /> X Contractor (9 W A/CAddress <br /> License No. Phone <br /> TYPE OF WELLlPUMP: NE ELL © WELL REPLACEMENT n DESTRUCTI ❑ out of Service 4lell L <br /> PUMP INSTALt.AT10 <br /> SYSTEM REPAIR ❑ THER O Monitoring Weil <br /> DISTANCE TO NEAREST; SEPTIC TANK WER LINES DISPaerXL FLD, PROP. LINE i <br /> FOUNDATION AGR TURE WELL THER WELL PtTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ST ION SPECIFICATIONS <br /> In Industrial © Open Bottom ❑ Manteca ' . e all Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 13 Tracy Type of Cas+ Specifications - <br /> ❑ Public Cl Other ❑ 0 Depth of Grout Se Type of Grout <br /> CJ Irritation Approk. Depth Eastern. Surface Seal Installed b <br /> Repair Work Done U Type of Pum H.P. State rk Done <br /> Walt Destruction O Well ' star Sealing Material i Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIRlADDITION Ll DESTRUCTION fNo septic system permitted if public sewer is <br /> ,. available within 200 leet.i <br /> Installation will serve: Residence i Commercial 'Other <br /> Number of living unity. Number of bedrooms <br /> r <br /> Character of soil to a depth of 3 feet: Water table depth t <br /> SEPTIC TANK. O Type/Mfg A'" Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 1 r► f'. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. b Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Wall Foundation Property Line <br /> a <br /> SEEPAGE PITS It Depth Size Number <br /> I SUMPS CI 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 San Joaquin County <br /> Home owner or licensed agent's signature certifies the fallowing: "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 subcontracting signature <br /> r <br /> i subject <br /> certifies the following: "I certify that in the performance of the work for which this permit :issued, !shall employ persons to workman's compensa- <br /> tion laws of California." <br /> The applican st call for all requiredinspe 'ons. Complete drawing on reverse side. <br /> [Signed Title: Date: /7 9` - <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by 4 1K Date Area <br /> PIS or Grout Inspection by Date Final Inspection <br /> Additional Comments <br /> Applicmt - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMtT'NO. <br /> INFOrem I y� <br /> . EK 13-24IREv,iinsi 01 LA .UG <br /> EK 14.2e <br />