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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ; <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 ; <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 Y1,6R FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work herein described. This <br /> application is make in caq�ilance vith San Joaquin County Ordinance No. 549 and 18 and the Rules fand Regulations of San <br /> Joaquin County Public Health Services. qsg r( - <br /> 1 V VIA 0 ity t ' creage <br /> Job Address U 1 <br /> Phone 3 <br /> ner's Nome t Address ' <br /> �t y,0,-W icense No. Phone 31- <br /> �rac�r dyes N p Out of Service Well ❑ <br /> WELL REPLACEMEN <br /> NEW WELL ❑ T OESTRUCTIO <br /> TYPE OF WELL/PUMP: OTHER ❑ Monitoring Well (3PUMP INSTALLATION E3 REPAIR <br /> REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL L r OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '+ <br /> © Manteca pia. of WeN Excavation• Dia. of Well Casing. <br /> i C7 I duatrial 0PenBottom '� � SpecrfrCations, - <br />" mestic/Private ❑ Gravel Pack ❑ Tracy Type of-Casing=---- <br /> / f [1 Delta Depth of Grout Seal �� Type of Gr <br /> Cl Other t <br /> i 1 Public <br /> I I Irrigation ...�.Approx. Depth 1 l tern Surface Seal Installed by <br /> Pu <br /> mp <br /> H.P. <br /> �' Stale Work Done <br /> Repair Work Done U Type of Pu <br /> Li Sealing Material i Depth <br /> Well Destruction O Well Diameter <br /> Depth 1111er Material i Depth <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I 1 avail blew tic hin 20stem feet.)permitted if public sewer is IZZ). <br /> Installation will serve: Residence Commercial — Other <br /> Number of living unite Number of bedrooms Water table depth <br /> Character of sop to a depth of 3 feet: No. Compartments <br /> 1 SEPTIC TANK D. Type/Mfg Capacity <br /> PKG.TREATMENT PLT. ❑ Method of Disposal <br /> ' n } Distance to.ossrest:_,.,�..Well. _Foundation..- <br /> Property Line <br /> LEACHING LINE 0 No. b Length of lines Total fengthlsize <br /> k FILTER BED ❑ Distance tfnsarsst: Well Foundation property Line <br /> o <br /> SEEPAGE PITS I I-Depthd�t Size Number l_t <br /> SUMPS a FLIrDistance to nearest: Well Foundation Property Line = vy <br /> k DISPOSAL PONDS C7 - ' 4. ! F� <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 /> ro . <br /> rules and regulations of the San Joaquin County, <br /> Home owner or licensed agent's-signaturs#o rtifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ sdV,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 unify t tin the performance of the work for which this permit is issued,I shall employ persons subject to workmiAn's compenss- <br /> tion laws o1 li nia." rt <br /> iont�fttfor ail r Yed in trona. Complete drawing on reverse de. <br /> TheSig <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> l <br /> Sq-Date Area t!S <br /> Application Accepted by• d/A <br /> o <br /> Pit r Grout Inspection by <br /> Date Final Inspection by Date l <br /> XT- <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEECK ` RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNTtR1EtMtTTEO CCASH E1413-24MEV.I/ItMQr�" <br /> EH 1626 <br />