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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 (Up� / -twin <br /> (209) 468-3447 <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 j <br /> application is etude in ceaapliance with San Joaquin unt dinance No. 549 and 1$62 and the Rules aad Regulations/of San <br /> Joaquin County Public Health services.!:SA#Af— RS-3, wo <br /> City ��"t Lot Site/Acreage <br /> h <br /> kob Address ! j <br /> �SS Phone G 0(` <br /> -s - <br /> KO <br /> Nome 't f �` Address <br /> 5?/�f X- <br /> � <br /> ontractor C� ► dlc�Cr t�Address License No. Z 7 Phone <br /> PE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ Out of Service Well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK'.___, SEWER LINES _._ LDISPOSAL FLD. _ _-_PRQP_. LINE * ` <br /> FOUNDATION AGRICULTURE WEL --OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Specifications <br /> U 'Domestic/Private D Gravel Pack _ ❑ Tracy Type of Casing - - <br /> 13 Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> GI Irrigation _,.Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump <br /> H,P. State Work Done f <br /> Sealing Material i Depth <br /> Well Destruction O Wei! Diameter <br /> % Depth % Filler Material 6 Depth <br /> TYPE OF SEPTI WORK: NEW INSTALLATION❑ REPAIRVADOITION 0 DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) 6� <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: r ' Water table depth t <br /> SEPTIC TANK. ❑ Type/Mfg - Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ' Total length/size ry ' <br /> FILTER BED n Distance to nearest: Well Foundation Property Lin I <br /> F <br /> 6 F • <br /> SEEPAGE PITS l I Depth Size Number t <br /> SUMPS U Distance to nearest: Welt ! Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby comity 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 signalure 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 Calilornis." Contractor's hiring or subcontracting signature <br /> certifies the following: 4'1 certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa• <br /> lion laws of California." <br /> o applicant Ior all r qu inspections. Complete drawing on reverse side. �? <br /> g <br /> gned Title: a fr Date: ` Z <br /> I DEPARTMENT USE ONLY <br /> Application Accepted by Date 4V Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> i <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN. P O BOX 2009, STOCKTON, CA 95201 <br /> ` FEE AMOUNT DUE OUNT REMITTEDM <br /> RECEIVED BY DATE PERM17 N0. <br /> 4? <br /> INFO �] <br /> . EH 13-24IREV.1M5 �v�� <br /> £H^�.7a <br />