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APPLICATION FOR PERMIT <br /> � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 MAR <br /> (209) 468-3447 €NVIRONiMENITAt_ HEALTH <br /> P 1 ^ MI_REN 1 YEAR PROM DATE .ISSUED PERM ITYSERdiC S <br /> (Complete in Triplicate) <br /> 1 <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This i <br /> application is rade in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Publ Health,�S�erv ,cee <br /> Job Address �l-Lm t _ i Cit Site/Acreage <br /> rr r <br /> Owner's Nsrh Addre Phone qf/y <br /> As <br /> Miense No. Phone9S(— <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPi_ACEME T I-1 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring well CZ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ` 'OTHER-WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mastic/Private C1 Gravel Pack 13Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Cl Irrigation —.Approx. Depth E stern Surfs seal Astzut d by <br /> Repair Work Done D Type of Pump H.P. ate Work Done. <br /> Well Destruction D Wall Diameter Sealing goteria"VDept - - <br /> Depth Filler Material i Depth f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 10 REPAIR/ADDITION M DESTRUCTION GI,(No septic system'permnted•if public sewer is <br /> ` ' available within 200 feet-1 ri <br /> Installation will serve: Residence Commercial_ Other - t <br /> Number of living unite Number of bedrooms y } <br /> r <br /> Character ofsoil,to a depth of 3 feet: t Water labia depth U) <br /> SEPTIC TANK © Type/Mfg Capacity " No. Compartments <br /> PKG. TREATMENT PLT,❑ �I �*` � Method of Disposal <br /> Distance to nearest: = Welt Foundation Property-Line- <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER SED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS If Depth Size Number h}'\ <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS —0— <br /> -1 <br /> 0—`I hereby certify thai 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 4 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature Ik <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 workman's compensa- <br /> tion laws of California." <br /> The applic ust all f all r quired insQections. mplate drawing on re rse'side. <br /> I <br /> S n Till DateQ [_� <br /> FOR DEPARTMENT USE ONLY ° <br /> 2 <br /> Application Accepted by Date '"qh Area µ <br /> Pit or Grout Inspection b(::__ Date Final tnspsction by Date L�Z r? <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 /> FEE INFO �/ AMOUNT Ot?E AMOUNT REMITTED CASH RECEIVED BY DATE P`ERMI7 NO. ' <br /> • EM 1374IREV,iiASr ) y'� Oiib <br /> EH?4I6 <br />