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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 . <br /> R <br /> (Complete in Triplicate) <br /> Application is hereby made,to Ban 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 ---�7!© 30 City 4 H"a0 to Lot Size/Acreage <br /> Owner's Name paAdl r �� �.� Address g �D Pho f003 �d <br /> ,O'Contractor s Address __�� ^� � License Noel y hone A4U4A <br /> - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION � AGRICULTURE WELL OTHER W jr PITS/SUMPS -_ <br /> INTENDED USE - TYPE OF WELL PROBLEM A CONSTRUCTIONSICATIONS I <br /> f7 Industrial ❑ Open Bottom ❑ Manteca Dr We cavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack L7 Tracy T Ca ' Specifications <br /> M Public I] Other ❑ Delta Depth of Grout S Type of Grout <br /> � Irrigation �.Approx. Depth Cl Eas Surface Seal installed by r n <br /> Repair Work Done U Type of Pump H.P, State Wo one �J <br /> Well Destruction ❑ Well Diameter Stealing Material i Depth 1 <br /> Depth Filler Material i Depth ; <br /> TYPE OF SEPTIC WORK; NEW"INSTALLATION fl REPAIR/ADDITION M DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence--. Commercial/— Other <br /> r Number of living units: Number of bedrooms <br /> Character of tioii to a depth of 3 feet: Water {table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. Cl s Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> F <br /> LEACHING LINE Cl No. & Length of lines Total length/size S <br /> FILTER BED [.l Distance to nearest: Well Foundation Property Line' j <br /> SEEPAGE PITS 11 Depth Size Number + <br /> SUMPS LI Distance to nearest: Well Foundation Property Linell <br /> DISPOSAL PONDS ❑ <br /> I hereby comity 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 <br /> employ any person in such manner as to become subject to workme .lwhich this permit is issued, I shall not <br /> n's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall employ persons subiect to workman's compensa- <br /> tion laws of California." <br /> The applicant must pall for all required inspections. Complete drawingon averse side. <br /> G i <br /> Signed Title: Date: <br /> I!QR DEPARTMENT USE ONLY r <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection b Dats <br /> I <br /> Additional Comments, <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ^ <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 1 <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT <br /> NO. <br /> ASH <br /> • EN 13-2I rREV.1 5) rr 1 <br />