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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIMTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 snide in cosIpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin CountyPublicHealth Services. <br /> Job Address F -' V L06jE _ `^_ CityLot Size/Acreage _ L <br /> Owner's Name !D � Address r i S' • Phone 9 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 /> 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f:l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other Fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth biller Material i Depth (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION [ I INo septic system permitted it public sewer is 9 <br /> available within 200 feet.) <br /> lnstallaeion will serve: Residence __ Commercial_ Other� > b <br /> Number of living units: Number of bedrooms <br /> s <br /> Character of soil to a depth o/�3 fest: Water table depth <br /> SEPTIC TANK. l��Type/MfQ Capacity I2-dC No. Compartments <br /> PKG. TREATMENT PLT, Ll f.� Method of Dispofal 4 <br /> Distance to nearest: Well Foundation ._ Property Line 1` <br /> �3 <br /> LEACHING LINE No. fl Length of lines Toty-length/size <br /> FILTER BED p Distance to nearest: Well G i3 Foundation 1 <br /> Property Eine <br /> SEEPAGE PITS I 1 Depth Size Number y6 <br /> SUMPS LI Distance to nearest: Well Foundation Property Line [ a <br /> SAL PONDS ❑ �. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Homs owner or licensed agent's signature oenifies 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 subcontracting signature <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 /> Thio apptlica�stcall I r inspections. Complete drawing on reverse sid""e.""Signed) Title: � e.r� c� Date: <br /> � DEPARTMENT USE ONLY <br /> Application Accepted by ,10 Date ren <br /> Ph or Grout Inspection by Date Final Inspection b Date <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 O Box 2009, Stkn, CA 95201 <br /> INFE AMOUNT DkJE Iff "fic5ra <br /> OUNTyREMITTED CASH RECEIVED BY DATE (`PERERMIT'NO.,��1/ <br /> , EH 14-211REV.ainIIr `� crag �� ��� I"9� ("1�`^ 5 <br /> EH i�•'6 <br />