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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 i <br /> PERM T -EXPIRES I YEAR FR M DATE ISS11ED <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 comiliance with San Joaquin county Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name ..__ r AddressPhone <br /> Contractor "JZAddresser r ense No.>' Phone 3 Q <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION'❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ ;- .—SYSTEM-RERAIR D +'� 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 /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wefl Excavation Die, of Well Casing <br /> FI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Il Public El Other f-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrivalion —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing (Materialh <br /> Depth i Filler Naterial�&Zpth <br /> f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR ADDITION (V DESTRUCTION I l INo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation wdl 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 ❑ Type/Mfg ILI CsPacitY_Z_JLV12 No. Compartments <br /> PKG. TREATMENT PLT.❑ r Method of Disposal <br /> Distance to nearest: Well 1p nda6on Property Line <br /> LEACHING LINE ❑ No. ✓!i Length of lines _. Totaf length/size ' <br /> FILTER BED O Distance to nearest: Well Foundation y Property Line <br /> 4E PITS 11 Depth iza ,Nc�umber t <br /> LI Distance to nearest: Well dation__ (1._� Property Line j a <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 PP <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 l <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 applicant mus call or alt u' inspections. C plots drawing on reverse side. <br /> Signed Title: �� / <br /> Date: <br /> FOR DEPARTMENT SE ONLY <br /> Application Accepted by Date Area ] w <br /> Pit or Grout Inspection by Date Final Inspection by Gl_, „ Date� ` <br /> Additional Comments: r , <br /> Applicant - Return all copies to: Ban Joaquin ounty Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 �F <br /> (4 Met �U, <br /> CK 41 <br /> IMFO AMOUNT OUf2 AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. 0 � ' <br /> 0 � <br /> • EH t}21(REV,1/N 5) IT <br /> EM t/.7s J 1 �f , o d °� <br />