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r111% APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct end/or ins,�al.l the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 9 and 1862 nd the Rules and Regulations of San <br /> Joaquin County Public Health services. - <br /> Job Address City WE rnT Lot Size/Acreage <br /> Owner's j Address Jkql � ftp Phone <br /> Contra or Address ) License No.-z ne � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION PrOut of Service Well <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 /> rl Industrial 0 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack n Tracy Type of Casing Specifications <br /> M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Gl Irrigation Approx. Depth D Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump �''"� H.P. State Work Done <br /> Well Destruction ❑ Well Diameter _[ � sealing Material & Depth <br /> Depth Filler Material i Depth u fid. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feel.) <br /> Installation will serve: Residence— Commercial_ Other [� <br /> Number of living units: Number of bedroorrisn In <br /> Character of soil to a depth of 3 feet: a r table depth <br /> SEPTIC TANK ❑ Type/Mfg a a w Compartmenta <br /> PKG, TREATMENT PLT. 0 Permit may hale expired w,�,�,u�Ulethod of Disposal <br /> Distance to nearest: F ti t' rope�Iy Line <br /> "'v�g �' �iAeori#ns & <br /> LEACHING LINE D No. & Length of lines ^ 1kP9i'yh39 Mrze <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 that in the performance of the work for which this permit is issued, I shall not <br /> employ any pen�u in such manner as to become subpct to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fol wing; "I certify that in the perlor ajofihetork forwhich this permit is issued, I shall employ persons subject to workman's compensa-tion laws of C Iifor"isThe applica mu ca 11or e inspgG nsrawing on re side. <br /> Signed '""- � /2 <br /> 9 Title: � Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date / Area / <br /> Pit or Grout inspection by Date Final Inspection by pate <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 /> INFO AMOUNT <br /> 0U AMOUNT REMITTED [ASHK 0 RECEIVED BY DATE <br /> . EH ta•24 IrtEv.1/45s ° �V Ori V ` ��^2��IdIm <br /> EH 13'21 <br />