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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 tz u` 7 <br /> (209) 46$-5447 SEP 1 -fin <br /> YEAR PROM DATE ISSR 1RONMENTAL HEAL TH <br /> (Complete in Triplicate) <br /> PERM!T/SERIdl <br /> .pplication In hereby made,to San Joaquin County for a permit to construct and/or install the work herein des ed. This <br /> ppllcation Is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules aad Regulations of San <br /> Jloaquin County Public Health Services, <br /> I. Ci Lot Size/Acreage <br /> Job Address <br /> Owner's NameddressPhone <br /> 11 <br /> GoGpt A res C icense No. Phone <br /> TIYPE Of WELL/PUMP: NEW WELL O WELL REPLACEMENT _ DESTRUCTION ❑ Out of Service Well Cl -� <br /> PUMP INSTALLATION SYSTEM REPAIR L] OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> il; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> `^- "INTENDED'U5E- TYPE"OF'WELL- PROS LEM'AREA'""-CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (n <br /> loll <br /> b <br /> omastic/Private _ 0 Gravel Peck ❑ Tracy Type of Casing Specifications <br /> M Public I-1 Other ❑ Delta Depth of Grout Sea! Type of Groin <br /> CJ Ifngation —Approx. De th Eastern QSurface Seal Installed by - <br /> Repaif Work Done. _ Type of Pump r f H.P. IL - State Work Done F <br /> Well Destruction v❑\ Well Dia,.-.-. Sealing Material i Depth ' <br /> �hDepth ! Piller Material i Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION Ll DESTRUCTION CI (No septic.-system permitted if public sewer is <br /> availablewithin200 feet.) <br /> !Installation will serve: Residence— Commercial— Other <br /> Number of living units: Numbeyfof bedrooms <br /> Character of soil to a depth of 3 feel: -+ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg . Capacity No. Compartments <br /> ` + <br /> PKG. TREATINENT PLT. C1 } . a _ -. � ...- i Method ofDi>posal <br /> bo Distance to nearest: Well Foundation Property Line <br /> V i LFEACHING LINE 0 No. & Length of lines J Total length/size <br /> V � + <br /> FILTER 9Distance neares <br /> EO [_l Disttt: OwlFoundatipn Property Lina <br /> J[ <br /> SEEPAGE PITS I I Depth rSize Number <br /> SUMPS L1 Distance to nearest: Well T r Foundation—'Property Line <br /> DISPOSAL PONOS ❑ <br /> _I�heraby certify that I-have prepared this-application and that therworr"it-be-done-in accordance-with-San-Joaquin coiutty ordinances, state laws, and--"' <br /> rules and regulations of the San Joaquin County 1 <br /> Home owner or licensed agent's signature cartifies 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 comity 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 call of uired inspections, Complete drawing on revVo side. <br /> Sig ed Title: Date: <br /> FOR DEPARTMENT USE ONLY �J <br /> A6pplication Accepted by Date Area Z'` <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> !F <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O DOR 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. <br /> INFO GASH <br /> . EH 13.4 IREV,Iin51 <br /> EH 9/� Q I5 <br />