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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> REMIT AS ,.I..YEAR ?ROlf-DATE ,L SSUEI7 <br /> (Complete in Triplicate) <br /> Application is hereby made,to San 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 Q LCity Lot Size/Acreage <br /> Owner's Name � Address Phone <br /> r^ �r �T <br /> Contractor f` Address �,� License No?r � �___Phone � <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT C7 DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION 4111� 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 _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ <br /> C] Industrial O Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing <br /> Domestic/Private Gl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> D Public ('1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation Approx, Depth 0 Eastern i Surface Seal installed by <br /> Repair Work Done ';t�, Type of Pump M,P, State Work Dane <br /> Walt Destruction D Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION LT DESTRUCTION EJ INo septic system permitted if public sewer is <br /> available within 200 feet.) C? <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms (/- <br /> Character of Goll to a depth of 3 feet: - ZWater table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity s No. Compartments <br /> PKG, TREATMENT PL-T.D '` Method of Disposal - <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ED Distance to nearest: Well Foundation Property Line 10. <br /> - { <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS ILI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby sanity 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 cenifies the following: "I cenify 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 becoms subject to workman's compensation laws of California." Contracioi's hiring or subcontracting signature <br /> cenifies 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 Cahfornls." <br /> The applicant 11P all required inspections. Complete drawing on reverse side. <br /> Signed X Title Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date / � Area - <br /> Pit or Grout Inspection by Date- Final Inspection by Date <br /> Additional Comments: <br /> IZ <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 2408, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EN 1]•24IREV.I/n51 Jl�f <br /> EN ti•Zs CCC.../// ��' r (/ <br />