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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> _- <br /> PERMIT EXPIRES 1 YEAR_ _FROM 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 ccuiliance with Ban Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San 1 <br /> Joaquin County Public Health Services. <br /> Job Address ( Scl G City G v Lot Size/Acreage- <br /> Owner's Name �� �� C Address �" J �. Phone Z f <br /> lo <br /> Contractor f2w6JE11-17- Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 1 OTHER ❑ Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1 <br /> I'I Public 1'7 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth. "I�I Eastern 1 Surface Seal Installed by <br /> Repair Work Done U Type of Pump _ � H.P. ^ L v r State Work Done n <br /> Well Destruction ❑ Well Diameter Sealing Me rial L Depth ►�J <br /> Depth Filler Material i Depth u <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION tZ DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED C) 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 laws, and t� <br /> rules and regulations of the San Joaquin County 4 <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 rpust fall for all r pections. Complete drawing on reverse side. <br /> Signed XTitle: . o Date: <br /> �im <br /> PARTMENT USE ONLY '2 <br /> Application Accepted by Gym Ra . , Date r s �`� Area <br /> Pit or Grout Inspection by Date Final Inspection by «r Date <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, CA 95201 <br /> IEEENFO AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 1144 IIIEY,I/M 5) i/L <br /> EH 14.16 ] / <br />