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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY ±PUBLIC EEA.LTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> t (209) 468-3447 . <br /> i Y R <br /> (Complete in Triplicate) <br /> Application In 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 vith San Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> C / �. <br /> Job Address <br /> 3 Cit Lot Size/Acreage oL <br /> I Owner's Name F Address/ d4� <br /> ✓Phone ro <br /> Contractor Address A �� <br /> C.dCLicense No. 3 Phone <br /> TYPE OF WELL/PUMP:JC NEW WELL.$! WELL REPLACEMENT n DESTRUCTION ❑ Dut of Service Well <br /> C1 <br /> PUMP INSTALLATION SYSTEM REPAIR C1 OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TAMC D ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> � FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA dpNSTRUCTION SPECIFICATIONS <br /> L7 Industrial <br /> 15-0p;11 Banom © Manteca pia. of Well Excavation <br /> eOOmestic/PrivateGravel Pack- C] Tracy Type of Casing Dia. of Well Casing <br /> . � <br /> M Public (.� Ot r Specilications <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> Ct Irngatron el�pprox. Depth ❑ Ea s m Surface Seal Iristalled by <br /> Repair Work Done U Type of Pump ly <br /> Well Destruction ❑ Well Diameter 174;�— Sealing Material i Depth State work Dona <br /> Depth Filler Material & Depth .O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION L7 DESTRUCTION GI.INo septic system permitted if public sewer is <br /> Installation will serve: Residence_,•� Commercial.--•. Other <br /> available within 200 feet.) I <br /> I Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: e <br /> SEPTIC TANK ❑ type/Mfg water table depth <br /> PKG. TREATMENT PLT, C1 Capacity_ No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation �^ r <br /> Property Line <br /> LEACHING LINE <br /> ❑ No. & Length of lines Total length/size <br /> FILTER BED n *Distance to 1 crest: WeR <br /> Foundation Property Line <br /> SEEPAGE PITS 11 Depth f <br /> p —Size - Number <br /> SUMPS CI Distance to nearest: well <br /> Foundation Property Line <br /> 'DISPOSAL-PONDS ❑ m= , 7 <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 Cdunty <br /> Home owner or licensed agent's signature certifies the fotlowing: "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 - sub-contracting signature <br /> certifies the following: 1 certify that in the performance of the work for which thin permit is issued, I shall amp persons subject to workman's compensa• <br /> tlan laws of California." a <br /> The applicant ust i for all require tions. Complete drawing on reverse side. <br /> Signed - ' <br /> Title: Date: <br /> . F ENT.USE ONLY � 1 <br /> Application Accepted by <br /> Data Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection byDate. <br /> Additional Comments: <br /> Applicant - Return all co !ee to: t — <br /> P SAN JOAQOIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES- <br /> 445 N SAN JOAQUIN, P O*BOX,2009, STOCKTON, CA 95201 <br /> r FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> EM 13.24 IAEV.I/EM 14-26 a sr Aii - <br /> e, <br /> I M <br />