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6 <br /> 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 /> -PERMIT� YEAR =M DATR ISSUSQ <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 mads in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address + City � � Lot Site/Acreage <br /> Owner's Name PD tt/ _ ,t � -- Address Phone <br /> Contractor Address n. 9 <br /> cense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O y WELL REPLACEMENT ❑ DESTRUCTION Out of Service well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK 3 SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION { _AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> 0 Industrial O Open Bottom C3 Manteca Dia. of Well Excavation -" Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications <br /> M Public I-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U 'Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material L Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 REPAIR/ADOITION L7 OESTRUCTION)R INo septic system permitted if public sewer is (A j <br /> available within 100 feet.) <br /> Installation will serve: Residence._ Commercial— Other <br /> Number of living units. I Number of bedrooms i s <br /> Character of $oil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Comport. nts, <br /> PKG. TREATMENT PLT, C] Method of Dr"sal..-.~ <br /> Distance to nearest: Well Foundation Property Line r <br /> a <br /> LEACHING LINE Cl No. & Length of lines Total length/size # <br /> FILTER BED 171 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire 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, state laws, and <br /> rules and regulations of the Sen 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 subcontracting 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 iifornia." <br /> The applic ust call fo required pe ti S. Complete drawing on reverse side. y <br /> ,a ( ' <br /> f <br /> SignedTide: 3 s Data: 3J 20 <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by__4z& Data - 7 Area t <br /> / <br /> PIS or Grout Inspection by Date Final Inspection by Date <br /> _T___T_ <br /> Additional Comments: € t 4 <br /> Applicant - Return all copias to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMiTT€0 CK RECEIVED 8Y PATE P€RMlT'NO. " <br /> INFO CASH <br /> EN 13 24(AEV,1/M5k 0 <br /> 0 `! �(�'3rV <br />