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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL'HlRALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> J!ERMIT EXPIRES YEAR-FROM DATE -ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a Permit to construct and/or install the vork herein described: This <br /> application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ' City ' Lot 81ze/Acreage49 <br /> Owner's ame / 6 Q r✓ems h��j �K""'dress' Phone <br /> Contractor tAw. t Addis 'Q A License No.�. hone <br /> TYPE OF WELL/PUMP: NEW WELkAOW� WELL REPLACEMENT n DESTRUCTION t of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 *, OTHER 13 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES DISPOSAL FLD. PROP. LINE `J <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS = C> <br /> C7 Ind trial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Die. of Well Casing <br /> IF on <br /> W�DomesticlPrivate ❑ Gravel Pack i ❑ Tracy Type of Casing_ Specifications <br /> i'1 Public fl other <br /> 1-1 Depth of Grout Seal Typa�of Grout <br /> 11 Ifrioation —Approx. Depth' I I'Eastern � Surface Seal Installed by ��,,.,.A (,!L�4e� <br /> k Repair Work Done L�]/Typs of Pump H.P. - tate W Done <br /> Wall Destruction Or Well Diameter t Sealing Materiel a Depth ` <br /> Depth .,,rLA0p !'filler Material a Depth + <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11REPAIR/ADDITION l I DESTRUCTION I 1 1No septic system permitted if public sewer is <br /> REPAIR. available within 200 feat.I - <br /> Installation will serve: Residence C7ciat— Other <br /> Number of living units. Number of ms Y P <br /> Character of SOA to a depth of 3 fest: L/ Water table depth <br /> SEPTIC TANK: ❑ Type/Mfg Aspac t No. Compartments <br /> PKG, TREATMENT PLT.0 k � ? Method of Disposal <br /> Distance to nearest: Weil ...Foundation- -- Property.Line <br /> LEACHING LINE ❑ No. 6 Length?of.linesM\ _ Total tengtVsi:e <br /> FILTER BED ❑ Distance to neareiit." F Well undation r " a 3" a Property Lina r <br /> SEEPAGE PITS 11 Depth L Number <br /> SUMPS Irl Distance to nearest: Wall "Foundation Propertj+ 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 - d <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 parso uc neer ss to become subject to workman's compensation laws of Colilornia."Contractor's hiring or sub-contracting signature <br /> certifNs the fo nq: "I card that in the perfo nce o a ork for Which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of sofornle." <br /> The appy t st 1uil <br /> ad' C ete a verse"side. <br /> Sign Title: Date: <br /> R PARTMENT USE ONLY ' <br /> Application Accepted by �. -. - _ <br /> Date _ Area <br /> Pit or Grout inspection by Date Final Inspection by <br /> Additional Comments:= <br /> Applicant - Return all copies to: Sii J66:quin. County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N`San`Joaquin, P O Box 2009, Stkn, CA 95201 <br /> c <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'Nb <br /> INFO CASH <br /> . EH 1Y2r IREV.t i r<s+�a f C1 O Q`0 0 <br /> IiN tM]a Yv V <br />