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,ki EMM <br /> APPLICATION FOR PERMIT � 4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION APR 2 <br /> P 0 BOX 2009, STMKTON, CA 9520fNVIRONMENTAL HEALTH <br /> (209) 468-3447 PERMIT/SERVICES <br /> PERMIT EXPIRE5 1 YEAR_PROM DATE ISSUED <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> i Joaquin County Public Health Services. <br /> Job Address _ l City Lot Size/Acreage <br /> Owner's NamaL - Address <br /> /I rAl Phone .O <br /> Contractor Addres d4i4tLicense No..26-S_7 -Phope <br /> TYPE OF WELL/PUMP: n NEW WELL-0_ _ WELL.REPLACEMENT _. _ DESTRUCTION Ll Out of Service,Well ❑ <br /> PUMP INSTALLATION ❑ e� i SYSTEM REPAIR E) + 1 OTHER ❑ Monitoring Well U <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION f AGRICULTURE WELL" ' L OTHER WEL"CL: " "PITS/SUMPS <br /> INTENDED USE TYPE,'OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS <br /> fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> U Domestic/Private ❑ Gravel Pack n T►acy- —Type-of-Casiog�" -- - Specifications <br /> 1F Public � ._I_l Other ❑ Delta Depth of Grout Seal Type of Grout <br /> C� Irrigation __.Approx. Depth ❑ Eastern Surface Seal Installed by Q - l <br /> i <br /> Repair Work Done U Type of Pump _ M.P. S State Work Done <br /> Well Destruction ❑ Well Diameter <br /> 'c� ri Sealing Material i Depth i <br /> Depth Filler Material 4 Depth I <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION IJ REPAIA/ADDITION-LI-DESTRUCTION"GI-(No-septic-system-permitted if public sewer is <br /> a available within 200 feet.) r <br /> Installation will serve: Residence—. Commercial_ Other <br /> Number of living unite: Number of bedrooms <br /> Character of sail to a depth of 3'fest: Water table depth <br /> SEPTIC TANK O Type/Mfg I Capacity r No. Compartments <br /> PKG. TREATMENT PLT.❑ y .. ,. Method of Disposal <br /> " " Distance to nearest: Well Foundation Property Line (� <br /> ----"CEACHING LINE Cl No. $ Length of lines Total length/size <br /> .. <br /> ) <br /> FILTER BED """ n Distance to nearest:; Well Foundation Property Line <br /> l _ <br /> SEEPAGE PITS I I Depth Size Number <br /> .r <br /> SUMPS Ll Distance to nearest:' Well Foundation Property Line <br /> DISPOSAL PONDS _._p. ^" 3 <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 Josquin 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, 1 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 /> eartifie><t�fel "I_cernfy_[het-in-the.performance of the world f_or".which this trermit_is.issued,-i_shali.empioy-personssubject-to-workman's"compensa- <br /> tion laws o} C n <br /> The appNcan t call for all req d inspe, ns. Complete drawing on revers ide. <br /> Signed "at <br /> Title: � � v Date: <br /> Uu <br /> FOR DEPARTMENT-US"E-ONL-Y- °^ <br /> Application Accepted by Date __.�' '�� --- Area <br /> Pit or Grout Inepectian b Date i Final Inspection by_ `1 � Date <br /> �.a K .. <br /> Additional Comments: R t r s 1 I <br /> Applicant '- Return all copies�to: SAN JOAQUIN COUNTY PUBLIC HEALTH 9ERVICES <br /> , <br /> ENVIRONMENTAL HEALTH DIVISIONIPEPJIIT/SERVICES <br /> 445 N SAN JOAQUIN," P O`BOX 2009, STOCKTON; CA 95201 I f <br /> FEE Jf I <br /> { AMOUNT DUE AMOUNT REMITTED a RECEIVED BY � Y HATE t PERMIT"N0. <br /> INFO ASR 1 <br /> . EH1]-Y4+REV.11n}) - 0 <br /> EH <br /> EH:!•26, <br />