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4 <br /> 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 /> ,21"IT LUIRES 1_YEAR PROM DA19Si SUED. <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 cowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Puubbliicc Health Services. <br /> Job Address Lot Size/Acreage <br /> Owner's Name 00 Address _.___ r Phone <br /> Contractor ,n dress_0/��_ _ f�C.®l��License No. ���Phone <br /> TYPE OF WELL/PUMP: NEW WELL,20 WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well, 0 <br /> PUMP INSTALLATIO SYSTEM REPAIR 0 OTHER O Monitoringf� Well <br /> C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK JJSEWER LINES �'� DISPOSAL FLD.�' PROP. LINE <br /> FOUNDATION �nn AGRICULTURE WELL r== OTHER WELL �� PITS/SUMPS �� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> In industrial © Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> '.)rOomesuc/Private AX4ravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1-�1 -Other CI Delta Depth of Grout Seal Type of Grout <br /> M Irfioution FeyApprox, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump �� H.P. __ State Work Done <br /> Wolf Destruction © Well Diameter Sealing Material i Depth "V <br /> Depth Filler Material i Depth �\` <br /> TYPE OF SEPTIC WGRK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted if public sewer is V <br /> ` available within 200 leet.l <br /> Installation will serve: Residence Commercial Other <br /> L v <br /> Number of living units: Number of bedrooms <br /> Character of $oil to a depth of 3 feet: r <br /> Water table depth <br /> SEPTIC TANK ❑ 'Type/Mfg Capacity- No. Compartments <br /> PKG. TREATMENT PLT. CI' Method of Disposal <br /> Distance to nearest: Well Foundation property Line <br /> LEACHING LINE C1 No. & Length of lines Taal length/size <br /> FILTER BED (_9 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS if Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 j <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 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 applics us ire .' omplete drawing on reverse s <br /> Signed e; Alzl Data: <br /> 4EPARTMENT USE ONL <br /> Application Accepted by Dale l <br /> Area <br /> Pit or Grout Inspection by f, L/,_� Date�� G� Final Inspection by Date 3 <br /> Additional Comments; �`/pC . -S l G— lir f y/e <br /> 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE t'ERM1T'NO. <br /> INFO �j L)rJJ CASN ) �y <br /> EH 14.44 IRtiY.t1K51 1311 <br /> ✓ / <br />