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t . -0v APPLICATION FOR PERMIT , F <br /> ' >pt + <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES litl � 4 1 �rF, r� <br /> l <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009j, STOCKTON, CA 95201 NOV 7 1ggo <br /> (209) 468-3447 ENVIRONMENTAL HEALTH <br /> ,E>�RMITLPIRES 1—y ATE FUMED PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install .the work 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 Services. <br /> Job Address CiLot Size/Acreage 111 <br /> Owner's Name _ Address Phone rt <br /> ConiraCtor Address Phone <br /> - License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION mfg SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L1 <br /> _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL '+ `OTHER WELL J' PITSlSUMPS��"'��� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omssticlPrivate 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public fa Other 0 Delta Depth of Grout Seal Type of Grout <br /> M Irrigation —Approx. Depth ❑ Eastern F Surface Seal Installed by <br /> Repair Work Done 101 Type of Pump H.P. V-3-- — State Work Done _ <br /> Well Destruction O Well Diameter .- Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION 0- REPAIR/ADDITION,0 DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence._._,. Commercial_-Other <br /> Number of living units: Number of bedrooms , <br /> Character of soil to ■ depth of 3 feet: Water table depth <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> _,,PKG.;TREATMENT PLT. G7 Method of Disposal <br /> d" Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. $ Length of lines Total length/size <br /> FILTER BED Ia Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Siie Number <br /> SUMPS Cl -Distance to nearest: Well -- ;Foundation Property Line- <br /> I ` <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 /> Some 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 applicant must cal for all requireq.inspections.-Complete dt'awln9 ori ra%isrse'side'. <br /> Signed Title: Date: a <br /> F94 DEPARTMENT USE ONLY <br /> { Application Accepted by Date T Area <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> # Additional Comments: <br /> 4 Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 <br /> I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO nCASIi <br /> Eli 1321 tFIEV. nSY <br /> EN:1.26 <br />