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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> f P O-BOX 2009, STOCKTON, CA 95201 <br /> i <br /> 1PERMIT EXPIRES L YEAR FROM DATE I$SUBDD <br /> (Compl.ete' in Triplicate) <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application to made in ecupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services(. + <br /> VTL City Lot Size/Acreage <br /> Job Address [�, <br /> Owner's Name Address ` Tiri Phone 15 <br /> Contractor w 1 Address C• License No.C.S1 "f1�5(toy Phone b- W-414W- <br /> 1 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 1-1 DESTRUCTION D Out of Service Well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 1�a(bkd&IOTHER �4 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION.; - -`AGMCULTURE'WEL-L— 0"='�-OTHER WELL�= = _- 'PITS/SUMP -- -F <br /> " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing <br /> C] Domestic/Private 0 Gravel Peck ❑ Tracy Type of Casing_ Specifications <br /> 11 Public 1-1 Other 1'1 Dena Depth of Grout Seat Type of Grout <br /> I I Irrigation _ _-__.Approx. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done U Type of Pump H.P. St, <br /> tq Work �*% <br /> r Well Destruction O Well Diameter Sealing Material ik Depth t <br /> t Depth 1 Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public saw at is <br /> ,.,t available within 200 feet.) <br /> Installation will serve: Residence' Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to A depth of 3 feet. Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> r PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation PropeT LIRIIQ�7H SOUNTy <br /> DISPOSAL PONDS ❑ NwRp RV <br /> I hereby cenify{that i have prepared this application and that the work will be done in accordance with San Joaquin county an <br /> rules and regulations of the Sen 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 shell not <br /> employ Any person in such manner as to become subject to workman's compensation taws 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 subject to workman's compensa- <br /> tion laws of California." <br /> The a s for r uirsd inspections. Complete drawing on reverse side. <br /> 4 <br /> Signed itle: "3..L_e P t - Date: 4 <br /> F EPARTMENT USE ONLY <br /> Y Application Accepted byDate Area cy o <br /> //A <br /> Pit or Grout Inspection by Moj? Date Y�30'_fj Final Inspection by Date ` <br /> Additional Comments: + <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> r <br /> Environmental Health Permit/Services <br /> 495 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> IEEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATE PERWV7 O. <br /> . EM 13.24(REV.1/n 5) O 00 <br /> EH 11.26d C9 / <br />