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APPLICATION FOR PERMIT " <br /> SAN JOA UIN COUNTY UNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N. 1S�N JOAQUIN, PHONE (209)468-3420 <br /> P'O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Fii <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 ceatpliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Cit Lot Size/Acreage <br /> Owner's Nam , r7`,lh 1, '�.i Address <br /> F1 <br /> one ; <br /> Contractor Address License No. Phone ' <br /> L TYPE OF WELL/PUMP: NEW WELL 7 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service' .- <br /> -Well ❑: <br /> #_ PUMP INSTALLATION''[] SYSTEM REPAIRJ01,0 OTHER ❑ Moriitoring 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 /> - CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -� <br /> F-1 Domestic/Private ❑ Gravel Pack* ❑ Tracy Type of Casing_ Specifications_� <br /> I'1 Public C3 Other 11 Delta Depth of Grout Seal Type of Grout' <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> WOR Destruetion ❑ 'WOIf Diameter Sealing Material i Depth <br /> Depth = Filler Material ti Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> available within 200 last.) ^�-- <br /> Instaliation will serve: Residence— Commercial_ Other p <br /> Number of living units: Number of bedrooms <br /> I Charsaw of soil to a depth of 3 feeC <br /> Water labia depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT,❑-- - Method of Disposal <br /> bbb Distance to nearest: Well Foundation Property Line <br /> i LEACHING LINE Ll No. b Length of lines Total length/size <br /> 1 <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> r SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> Fi <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 signature certifies the following: "I certify thatin 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 workmari's compensa- <br /> tion laws of California." <br /> The applicant t call for ph required inspections.-Complete drawing on reverse side. <br /> Signed ' ✓ r Title: <br /> Dat .7— <br /> FOR DEPARTMENT SIE ONLY <br /> ### Application Accepted by Oate Area <br /> 1 Pit or Grout Inspection by Date' Final Inspection b Date 1 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County public Health Services <br /> Environmental Health Permit/Services <br /> j 445 N San Joaquin, P O Box 2005, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED - <br /> BY DATE PERMITN0. <br /> INFO CASH ' <br /> °.H'14-Ill <br /> F <br /> 13-24(REV,I/As ^�� !J✓/��Ay � � l �� <br />