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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIMTAL HEALTH DIVISION <br /> 1445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCK TON, CA 95201 <br /> iPERM I T E%P I RE S 1 YEAR FROM DATE I S SUED <br /> (Complete in Triplicate) <br /> i <br /> t Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> Ru <br /> application is made in con6liance'vith San Joaquin County Ordinance No. 549 and 1862 and the les and Regulations of San <br /> Joaquin County Public Health Services. <br /> J <br /> I/Job Address - `v C City Lot Site/Acreage <br /> 'Owner's Name __ Address 7 <br />! t✓ Phone <br /> Contractor J' Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service well ❑ <br /> =PUMP INSTALLATION ❑ SYSTEM REOAIR ❑ 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 /> Cl Industrial = ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private ❑ Gravel Pac.k7 ❑ Tracy Type of Casing Specifications \ <br /> 11 Public t,-- --1-1,Other``��� n Delta Depth of Grout Seat ---- - Type of Grout t� <br /> I I Irrigation Approx.'Oepth . I I Eastern Surface Seal Installed by <br /> Repair Work Done Ll Type of Pump H•P. State Work Done <br /> Wall Destruction ❑ Well Diameter Sealing Material R Depth <br /> Depth biller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION {No septic system permitted it publ" of is <br /> available within 200 feet.l <br /> stalletion will serve: Residence T Commercial,— Other <br /> Nu of living units: Number of bedrooms <br /> Character to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Ca <br /> petit No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to t: - Well pundation Property Line <br /> LEACHING LINE ❑ No. b Length of line Total lengthtsize <br /> FILTER BED 0 Distance to est: Wall ation Property Line <br /> SEEPAGE PITS i th Size r <br /> SUMPS 1 01Distance to nearest: Wall foundation Pr Line <br /> I h by certify that I have prepared this application and that the work will be done in accordance with San Joaquin co 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 performanes of the work for which this permit usd, I shall not <br /> employ any person in such manner as to bticome subject to workman's compensation laws of California."Contractor's hiring or sub contr 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 c n ca- <br /> tion laws of California." <br /> The applicant must call for all squired inspgctions. Complete drawing on reverse side. <br /> Signed Title: Date: 3J <br /> � 7 ? <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Ph or Grout Inspection by Date final Inspection by Date C <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 /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DA PERMIT'N0. <br /> . EH 13-24(REV.�ir15! .t C� �`•"' y '.,[_ I <br /> EH 14.20 <br />