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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 /> PERMIT EXPIRE9 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application SO hereby made.to San Joaquin County for a Permit to construct and/or install the vork herein described. This <br /> application Ss made in ccepliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaqul0 County Public Health 7Servviccels. <br /> Job Address �( 2�O�Y 4,,,V;ij jfi City Lot Size/Acreage <br /> Ownar's Name / 7'y Address .,. <br /> ff1y Phone <br /> Contracts / <br /> Address �U• 'O '<e1ZVAe(7License No m' Phone <br /> TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ Monitoring Well ❑ <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 /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> L) Domestic/Privaia ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> - <br /> [1 Public T7 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ �• <br /> WON Destruction ❑ WON Diameter Sealing Material A Depth <br /> Depth Filler Material a Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public "we, is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: _ Number of bedrooms <br /> Character of 11011 to a depth of 3 fest: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg i4kFW , Capacity _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well�3J31 inundation 167 Property Lino <br /> LEACHING LINE Ll No. g Length of lines T —�d� �T_ Total length/sire <br /> FILTER BED ❑ Distance to merest: Well 41ahc) V­F6undetion Property Lints —h=7— <br /> SEEPAGE <br /> h ''/=7— <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS - LI Distance, to nsaroat: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> Horns owner or licensed agent's signature cenifios the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any parson in such manner as to become subject to workman's comper ssh'Ion laws of Cslifo(nis.''Contractor's hiring or sub-contiactino signature <br /> unifies the following: "I certify that in the performance of the work for which this permit Is issued, 1 shall employ persons subject to workman's compena <br /> tan taws of California." <br /> The applicant moat call for I req ad inspections. Complete drawing on r ms <br /> Signed K Title: —16 - - Date: <br /> FOR DEPARTMENT USE ONLY /� q <br /> Application Accepted by e( . ,I1 JA, � Date IN G- / Z Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Addhional 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, OA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OA,ryT'E�-f) PERMIT NO. <br /> • EN 1.r1881REv.11e9) .1D r OU 8 / �" / !� 132. <br /> 1- 7 <br />