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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONKMTAL HEALTH DIVISION <br /> p 445 N SAN JOAQUIN, PHONE (209)468-3420 i <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM D�iTE IS3]gED <br /> (Complete in Triplicate) 1 <br /> Application In hereby made to Sew Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cestpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Elan <br /> Joaquin County Public Health Services. <br /> Job Address Le City Lot Size/Acreage <br /> Owner's Name Address -7n7 �J • - _J�_2 Phone <br /> ContractorAddress License No, hone <br /> TYPE OF WELL/PUMP: NEW WELL,$i(, WELL REPLACEME A DESTRUCT1 " of Service Well ❑ <br /> PUMP INSTALLATION ❑ 1 SYSTEM REPANLO OTHEk C Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i1 Dia. of Well Casing <br /> _ i <br /> XDomestic/Private 92 Gravel Pack 0 Tracy Type of Casing_G:�V%)C: Specifications -� \\ I <br /> I.1 Public Cl Other fl Delta Depth of Grout Seal L C)t7 Type of Grout 01 aw%�!t <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 T p <br /> p Type of Pum 'H.P. Staid Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth ` <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I f DESTRUCTION I 1 {No septic system permitted if public sewer is ' <br /> ' available within 200 lest.) <br /> Installation will serve: Residence Commercial Other i <br /> Number of living units: Number of bedrooms <br /> Character of sod to a depth of 3 feet: } Water table depth f TT) „{ <br /> SEPTIC TANK. ❑ Typi/Mfg Capacity No. Compartments <br /> ' PKG. TREATMENT PLT. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines f Total length/sire <br /> FILTER BED 1:1Distance to nearest= ` Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number t <br /> SUMPS LI Distance to nprest:-* Well Foundation Property Line 1 <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 San Joaquin County" ' <br /> Home owner or licensed agent's signattire 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•su6ject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I unify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- ! <br /> tion laws of California." <br /> i <br /> The applicant must call for all required Inspections. Complete drawing on reverse-side. <br /> Signed ` y Title: Date: <br /> `_ OR DEPARTMENT USE ONLY <br /> Application Accepted by 966A Date �— `--✓ Area �2 <br /> PK y �� !'/ Lf .vr Date <br /> Pit or rot ns floe b Date Final Inspection bti ¢,i <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 <br /> I <br /> INFO AMgOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO/. <br /> . EH1 <br /> 3-E4 MEV.t i n SI l/"� 1-- 5),-0-5)� <br /> EH 14.26 Cf9,00 <br /> 1 <br /> r— <br />