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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 /> PEWIT .EXPIRES _I_ YEAR FROX 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 /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Address 3 % Phone <br /> Contractor Address License No. Phone �6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT f'1 DESTRUCTION ❑ Out of Service We11 Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U <br /> DISTANCE-TO NEAREST: SEPTIC TANK------ SEWER LINES -"`" - -DISPOSA•t:­FLD;" — —PROP.-LINE-T =rt -- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t r <br /> ❑ Industrial `- p Open Bottom- . ❑ Manteca Dis. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack ❑:Tracy Type of Casing ] Specifications <br /> M Public f"1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irtiomion Approx. Depth ❑ Eastern �Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done �= { <br /> Well Destruction O Well Diameter Sealing Material i Depth �V13 <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION STRUCTION G (No septic system permitted if public sewer is <br /> � � available within 200 loot.) <br /> Installation will serve: Res' once Other <br /> Number of living units: Number of be ro ms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK p Type/Mfg CA 1,� Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 r Method of D2'701 <br /> Distance to nearest: Well Foundation __s Property Line <br /> LEACHING LINE moon & Length of linea t lerigth/sire <br /> FILTER BED f_7 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Site Number <br /> SUMPS LI Distance to nearest: Well Foundation property Line , <br /> DISPOSAL PONDS ❑ R <br /> i <br /> I hereby cenify 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 canities the following: 1 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 k-,r,7J, <br /> T <br /> as <br /> ,,, Q6_ C0plate drawing o reverse si e. <br /> Signs Title: . ,., .._,..,_ Date: <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date Q- Area <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by Datsr) O <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES W <br /> ENVIRONMENTAL HEALTH DIVISION PERiM1T/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2005, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE A MO <br /> REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . EH1,.24 1REV.t�rlbl ,C?� <br /> E <br /> I <br />