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I� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES F <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> �I P 0 BOX 2009, STOCKTON, CA 95201 • <br /> PEMIT EXPIRES FROM DATE <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 catapllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> ,,Joaquin Corny Public Health Services. _ <br /> �. <br /> C.J City Lot Size/Acreage <br /> Job Address 4 " <br /> Owner's Name <br /> - Address �✓ r Phone { <br /> No!Contractor I� ddress icense NoJ Phone�� <br /> TYPE OF WELL/PUMP: INEW OVELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well O ; <br /> Monitoring Well <br /> - PUMP,INSTALLATION O SYS <br /> TEM REPAIR ❑ OTHER D t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPiE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> of Well Casiri t <br /> CDia.7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g - t <br /> 'i" Type of Casin Specifications <br /> Ct DomesticlPrivate ❑ Gravel Pack ❑ Tracy g— ; <br /> I'1 Public Cl order 171 Delta Depth of Grout Seal Type of Grout <br /> I t Irrigation �.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done U "`'Type Of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material i Depth I O <br /> Oothi Filler Material i Depth { <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IF REPAIRIADDITION ( I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Ip <br /> Installation will serve: Residence_LCommercial_ Other <br /> Number of living units: L1M' Number"of bedrooms l77 <br /> I Character of soll to a depth of:3 feet: Water table depth <br /> I SEPTIC TANK ❑ Type/Mfg `� -- Capacity No. Compartments l <br /> PKG. TREATMENT PLT. ❑ ,� +-, Method h�of DisposalD amts to nearest: Well�LI� Foundation Property Line l�O— t <br /> LEACHtNG LINE ❑ No. 8 Length of lines ��-- _ Total length/size i <br /> t <br /> FILTER BED ❑ Distance to nearest: Weill Foundation Property Line . <br /> I ` <br /> SEEPAGE PITS I I Deplh '�w - Sill Number " <br /> SUMPS LI Distance to nearest: Well /d gr Foundation ^ Property Line <br /> I <br /> DISPOSAL PONDS ❑ i�, . <br /> 1 hereby certify that I have prepared ititpplication and that the work will be done in accordance with San Joaquin county ordinance state laws, and <br /> rules and regulations of the San Joaquin County <br /> that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent'i signature certifies thelollowing: "I certify <br /> employ any parson in such man ler as to become subject to workman's-compettotion taws 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 cmpensa- <br /> tion laws of California." <br /> The applicant $111 fo!AWI requir ins tions. Complete rawing on, <br /> rravirse side. <br /> Signed Title: I.. F Date: <br /> R DEPARTMENTSE UONLY <br /> r t p :Z L <br /> ° Application Accepted by Data 4 Area <br /> �or Grout Inspection by ateinal lnapection b Date <br /> Additional Comments: III <br /> III <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> yI Environmental Health Permit/Services <br /> I. 445 N San Joaquin, P O Box 2009, 8tkn, CA 95201 <br /> FEE AMOUNT OVE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> 9H 1124 MWt)RS1 - r <br /> EH t47a t <br />