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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 <br /> (249) 468-3447 <br /> YEAR rROM DATE <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the cork herein described. This <br /> application is [Dade in coupliance with Ban Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ��'�" City o2 Lot Size/Acreage <br /> Owner's Name Address Phone <br /> Conlraclor 4 &1z". - vlarrAddress zlj License No.lCkty -- --Phone A <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public I"i Other 0 Delta Depth of Grout Seal Type of Grout <br /> M Irrigation _.App(ox. Depth 0 Eastern Surface Soul Installed by <br /> Repair Work Done C7 Type of Pump H.P. State Work Done _ <br /> Well Destruction © Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth 4 , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRlADDITION DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 lost.) <br /> Installation will server Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet, f" ` Water table depth <br /> SEPTIC TANK. Type/Mfg j p K�'- t� Capacity.2-00_ No. Compartments <br /> PKG. TREATMENT PLT, 0 ' ,"; Method of Disposal <br /> Distance'to nearest: Well � Foundation ldC Property Line <br /> LEACHING LINE Ll No. & Length of lines t Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> I ` <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Al Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS , © / s <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 iaws, and <br /> rules and regulations of the Son Joaquin County ; <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 cienify 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 mull II for all required inspections. Complete drawing on reverse side, <br /> Signed ' Title: Data: &�f <br /> t <br /> AiFT-114TUSE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by /Date Final Inspection by Date_111_1! nl <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 0 BOX 2009, STOCKTON, CA 95201 <br /> x IEEE AMOUNT DUE AMOUNT REMITTED LASH RECEIVED BY ` DATE PERMIT'NO. <br /> . EH 13.24WEV.i/h51 +�� f}9 <br /> 5 EH',�.2a 17► <br />