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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES� •� �` ,i � <br /> ENVIRONMENTAL HEALTH DIVISION '1 <br /> P O BOX 2009, STOCKTON, CA 95201 JAN 2 <br /> F (209) 468--3447N1r (}r <br /> .•PEIMIT EXPIRES 1 YEARin P899 DATE Triplicate) <br /> (Complete <br /> # Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City 2:±A Lot Size/Acreage <br /> Owner's Name _,1 -:— a'ltz Address _ . Phone <br /> Contiact.7 Address License N pz Phone - l ' <br /> TYPE OF WELL/PUMP: " NEW WELL O WELL REPLACEMENT CJ DESTRUCTION 0 Out of Service we11 ❑ <br /> t _ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ' F1 Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Aomestic/Private 0 Gravel Pack C] Tracy Type of Casing Specifications <br /> 1..l Public (:] Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation —.Approx"Depth nd Eastern Surface Sedl Installed by r/1 <br /> w Repair Work Done Type of Pump e -+�� H.P. �' �— State Work Done <br /> 4 Well Destruction 13 Well Diameter ' Sealing Material i Depth IJ�f <br /> Depth Filler Material a Depth <br /> r TYPE OF SEPTIC WORK: NEW:INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CJ (No septic system permirted'if public sewer is <br /> r y- available within 200 leet.l <br /> ` installation will serve: Residence Commercial___. Other—.,­ <br /> Number <br /> therw Number of living units: Number of bedrooms 'r <br /> F Character of soil to a depth of 3 feet: IW table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity -�,No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance,to nearest: Well Foundation Property Line <br /> LEACHING LINE LD No. 8 Length of lines Total length/size <br /> FILTER 6ED n Distance t0 nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number / <br /> SUMPS Ll Distance to nearest; Well Foundation Property Lina <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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- <br /> tion laws of California." <br /> The applicant must call for all repu'ed inspections, Complete drawing on reverse side', <br /> � <br /> 3 Signed X _ Title: A = Date: <br /> i OR DEPARTMENT USE ONLY /� <br /> Application Accepted by Data f Area /� <br /> All <br /> Pit or Grout Inspection by Date Final Inspection by t Data a <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 98201 <br /> FEEL <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK III RECEIVED BY DATE PERMIT NO. <br /> . EH 13.241REV,rrx6) imp <br /> f EN 74•ie <br /> 1 <br />