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APPLICATION FOR PERMIT <br /> I ; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 �J <br /> (209) 468-3447 � ��� <br /> l <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for n permit to construct and/or )natal) the work herein described. This <br /> application is made in co:Wliance with Sa Joe in C ty Ordinance No. 549 and 1862and the Rule na gulat onsof an <br /> Joaquin County Public Health Sery/ices'. � � � � .2�3� � � /•� <br /> r ///� 2 LJ fI�/� l� / Clty <br /> Lot Rize/Acreage <br /> Job Addres>�� <br /> Owner's Nsme� ddress IQPhone <br /> T 3 <br /> Contracts / Addres License N Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION 17 SYSTEM REPAIR ❑ OTHER <br /> j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. --BASK--6INES <br /> E FOUNDATION AGRICULTURE WELL L.OTHER WELL <br /> P�TSES�MPS�U�S� <br /> iNTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation -947-vWdelf-E sing <br /> U Domestic/Private ❑"Gravel Pack ❑ Tracy Type of Casing aSpe-keetion <br /> M Public 1"1 Other ❑ Delta Depth of Grout Seal 1*pw_a�O—Z <br /> G Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by GQ �G <br /> Repair Work Done U Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 10 ,REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is C _ <br /> available within 240 feet,) �5 <br /> Installation will serve:" Residence— Commercial_"" Other <br /> t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, Cl Method of Disposal <br /> Distance to nearest: Welt Foundation Property Line <br /> LEACHING LINE ❑ No. 3 Length of lines Total length/sire C <br /> FILTER BED rt Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I "Depth Site Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line \\\ <br /> DISPOSAL PONDS o <br /> I 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 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 st ca11 for required inspections, Complete drawing on reverse side: <br /> Signed Y /r��_�D <br /> Title: <br /> iG� ��D�a+x/sT_ Date:. <br /> OR EPARTMENT USE ONLY. �7 J <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by !� Date Final Inspec ion by Date <br /> Additional Comments: r G r r — <br /> k if <br /> Applicant - Return a.l.l copies to. SAN JOAQUIN C . TY PUBLIC HEALTH SERVICES <br /> �j. ENVIRONMENTAL. HIRALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2000, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO dp CASH r►� o,� Q <br /> F . EH 14.24IREV.,/+•5I rfT(� iL LV 1 to • <br /> EH:�•2a <br />