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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 /> i <br /> ,. HERMIT EXPIRES 1 YEAR rRQM PATI) IbbJ>§jJ <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 1 <br /> application is made.in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin couAty Public <br /> aHealth <br /> sServices. <br /> XJob Address <br /> 1 GL }/[l / t f <br /> \/Owner's NameAddress Phoned <br /> Y Contractor�!. ,�z ddress Lscense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ oring Well <br /> DISTANCE TO NEAREST: SEP K SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER W PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL EA CONSTRUCTION FICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca of xcavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy ype o sing Specifications <br /> M Public 1-1 Other ❑ Depth of Grou al Type of Grout <br /> G trngauon _,Approx. De d Eastern Surface Seul Installs <br /> Repair Work pone U Type of P p H. State rk Doris <br /> �- <br /> Well Destruction ❑ W iameter Sealing Material A Depth ` <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION 0 iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve; Residence_ Com ercial_ Other _ <br /> Number of living units: Number of <br /> Character of soil to a depth of 3 feet: � Water table depth <br /> SEPTIC TANK ❑ Type/Mfg LL Capacity I x No. Compartments <br /> PKG. TREATMENT PLT.❑ Put 'T MaY have Wired without Method of Disposal <br /> Distance to nearesiliffOrk0bei d i Property Line <br /> Ge �} it e e <br /> g t_1- Lai eafh U—Vi A length/size <br /> LEACHING LINE Ll No. 8 Length of lines <br /> FILTER BED CI Distance to nearest: Well Foundation Property.,Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll 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 taws, and <br /> rules and regulations of the San Joaquin County I ; <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 must tail for al eq fired inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> PARTMENT USE ONLY <br /> Application Accepted by Datel—` — L Area <br /> Pit or Grout Inspection by Date Final inspection by Date <br /> Additional Comments: _ <br /> Applicant - Returu all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES f <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201FEE ; <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17 NO. <br /> . EH 13.74 IRt:V,1 r n 5) .>o .C)rj °33 r M <br /> EH <br />