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APPLICATION FOR PERMIT ^ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMMTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 Nmw m <br /> P O BOX 2009, STOCKTON, CA 95201 Q <br /> PERId T ESPIRES 1 'EM FROMD T SU Q.;,� lb"i'�3`P • <br /> (Complete in Triplicate) <br /> to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> Application is hereby raade, <br /> application is made in compliance with San Joaquin county Or <br /> No. 51+9 and 1862 and the Rules end Regulations of Ban <br /> Joaquin County Public Health Services. <br /> O O City Lot Size/Acreage 4 <br /> Job Address <br /> Li.-i <br /> Owner's Names Address - <br /> ' Phone <br /> Contractor <br /> Address License No. <br /> WELL REPLACEMENT n DESTRUCTION ❑ put of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 1:1OTHER ❑ Monitoring Well (3 <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> `DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL i <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> 0 Industrial C] Open Bottom ❑ TracyMantDia. of well Excavation Specifications <br /> n DomesticrPrivate ❑ Gravel Pack CS Tracy Type of Casing_ <br /> J-1 Other <br /> 1'1 Public <br /> Cl Delta Depth of Grout Seal Type of Grout <br /> — N <br /> I I Irrigation 3 Approx. Depth I 1 Eastern Surface Seal Installed by <br /> H.P. State Work Done _ <br /> Repair Work Done U Type of Pump Sealing Material E Depth <br /> Well Destruction O ' Well Diameter filler Material fs pepth_. <br /> Depth ��' "" -- — -- <br /> TYP SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 'availa la'w thin 200 feetc system fed it public sewer is <br /> Installation will se . esidence Commercial— Other <br /> ' r <br /> I Number of living units: bar of bedrooms F <br /> Water table <br /> Character of 804 to•depth of 3 fest: <br /> Capacity r;;No" partments = <br /> SEPTIC TANK: ❑ Typal Mfg Method of Disposal <br /> PKG. TREATMENT PLT.0 + q <br /> Distance to nearest: Well Founds Ptoperty.Line <br /> t <br /> I Totallen ire r <br /> LEACHING LINE 0 No. 8 Length of lines — <br /> FILTER BED Cl Distance to nearest: W -foundation - Propeny <br /> E f <br /> Si:e ' Number <br /> SEEPAGE PITS I I Depth # <br /> SUMPS L +stance to nearest: Well Foundation Property line <br /> t <br /> DISPOSAL POND- ❑ 1 ` <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, an <br /> rules and regulations of the San Joaquin County b .. _ <br /> t Home owner or licensed agent's signature certifies the following: "I certify that in the pee of rformancthe work for which this permit is issued, I all not <br /> sh <br /> k employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or iub contracting signetur <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject lo workman's compensa <br /> tion laws of California." <br /> The applicant or all required inspections. Complete drawing on reverse side. <br /> , Title: f Date: <br /> Signed — <br /> Off DEPARTMENT USE ONLY <br /> Date r r Z Ane 7- <br /> A <br /> A ation Accepted by <br /> fDate Finalinspectionby f Dotd <br /> Pit or Grout Inspection by <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 ox 2009, Stkn, CA 95201 <br /> FEE K RECEIVED BY DAT PERMIT N0. <br /> INFO AMOUNT DUE, AMOUNT REMIT <br /> EN 14-38 <br />