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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV I RONJMTAL HEALTH DIVISION <br /> ' 1 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 'PERMIT EXPIRES 1 YEAR FROM D TE ISSUED <br /> f <br /> (Complete in Triplicate) <br /> Application is hereby made to Han 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 Addresswo City Lot Size/Acreage <br /> i Owner's Name <br /> Address P gux Z6 f 2 Phone <br /> Contractor �( L � ddress <br /> tense No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION LK Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS A <br /> INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS �\ <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E.] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 0 Public 171 Other ' (1 Delta Depth of Grout Seal Type of Grout <br /> - <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump '1 H.P. St a Work Done <br /> We"Destruction bit 'Wall Diameter a 11�f,[r Seeing Material tc Depth <br /> Dapth�f1 Filler Material i Depth <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted it public sewer is <br /> available within 200 feet) <br /> Installation will serve: Residence_ Commercial— Other w <br /> i Number of living units:. Number of bedrooms <br /> Character of soli to a depth of 3 feet:1 Water table depth <br /> t SEPTIC TANK. 0 TypelMf9 Capacity No. Compartments <br /> ` PKG. TREATMENT PLT. ❑ Method of Disposal <br /> _ Distance to nearest: Well Foundation Property Line <br /> - LEACHING LINE 0 No. m Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth sue Number <br /> SUMPS _ Ll Distance io nearest: Well Foundation Property Line <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 sub-contracting signature <br /> certifies the following: "I certify that in the perlormance 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 appy sj for all i ir insPections. Complete drawing on r v rse aid . <br /> Signed Title Date: <br /> FOR DEPARTMENT USE ONLY 4 (' <br /> Application Accepted by yV - -- Date L-JArea <br /> 3 <br /> Ph or Grout Inspection by Date Final Inspection b Dat <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 0 Box,2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE r AMOUNT REMITTED t K RECEIVED BY DATE PERMIT'NO. <br /> INFO �]/�] g <br /> + EN 1�24INEV,uasi wU �a 11 6 �l /3 "Iy <br /> 4 , <br />