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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 /> PF"IT EXPIRES 1 YEAR 'ROH DATElSSUED <br /> (Complete in Triplicate) <br /> Application in 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ff <br /> Job Address ' �0` City Lot Size/Acrease �!]rff({r^[+ <br /> Owner's Name 1A T Address <br /> Phone <br /> Contractor pr,G &LA94 Address6 Or License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR L7 OTHER O Monitoring Well U t) <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 /> fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public (I Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Cl Irrigation __.Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material i Depth <br /> Depth Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Irl DESTRUCTION No septic system permitted if public sewer is <br /> available within 200 feet-1 <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of $oil to a depth of 3 feet: Water table depth �"r <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line w <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> �1 <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL_ PONDS 0 <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 nor <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic n must tail or all requir in tions. Complete drawing on reverse side. f <br /> �4k�' f <br /> Signed Title: Date: ,e*�.,�`� .......� <br /> FOR DEPARTMENT USE ONLY f.�1 <br /> Application Accepted by Date 12— 4'fe?6' Arae J <br /> Pit or Grout Inspection by Data Final Inspection b Date���t� , <br /> Additional Comments: • <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES "' <br /> ENVIRONMKNTAL HEALTH DIVISION PERWIT/SERVICES <br /> 945 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 65201 <br /> FEE <br /> INFO AMOUEMIT <br /> NT DUE A OUNT RTED CASH EI <br /> RECVED BY DATE PERMIT'NO. <br /> . EH rs.24 iHEv.„Kai '� _ 7d �'3 3 7 I <br /> EH 44.2e K02 I <br />