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i <br /> APPLICATION FOR PERMIT l <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EX R ORO DATE—ISSUED <br /> (Complete in Triplicate) <br /> t <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance,vith San Joaquin County Ordinance No. 549 artd 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. A <br /> City Lot Size/Acreage Z_9 <br /> Job Address �� �^7?e,fF /7 <br /> Address Cf * Phone <br /> Owner's Name "' <br /> Contractor C Address_261-02 License No. <br /> Phone <br /> f service Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 Out Moonitoring Well <br /> PUMP INSTALLATION ❑� SYSTEM REPAIR 0 OTHER ❑ <br /> �t SEWER-LINES ' '—" == F=- ISPOSALFL-D -- -.PROP,-LINE <br /> DISTANCE TO.NEAREST: SEPTIC TANK _. i <br /> FOUNDATION' AGRICULTURE WELL OTHER WELL PITSISUMPS �. r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q <br /> ( Industrial <br /> EI Bottom ❑ Manteca Dia. of Well E>rcavat'iori _ � Dia. of Well Casing <br /> Specifications <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> M Public 1-1 Other ❑,De1ta Depth of Grout,Seal = Type of Grout <br /> i <br /> �.Approx. Depth ❑ Eastern Surface S'sul'Installed by <br /> CJ Irrigation � <br /> Repair Work Done (J Type of Pump - ` H.P. State Work Dane <br /> Sealing Material 4 Depth t <br /> Well Destruction ❑ Well Diametert <br /> Depth iPiller Matertali Depth - € <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION 0 REPAIR/ADDITION 9S;DESTRUCTION (No septic system permitted i(,pttblic sewer is <br /> r ?available within 200 feet.] <br /> Installation will serve: Residence Commercial — Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 toot,�f Water table depth <br /> A <br /> SEPTIC TANK. O Type/Mfg I Capacity No. Compartments <br /> i "� � r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal r <br /> Distance to nearest: ;i'Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED C1 Distance to nearest: :Well Foundation Property Line <br /> f ,( <br /> SEEPAGE PITS 11 Depth f Size Number <br /> SUMPS LI Distance to nearest: •Well Foundation Property Line <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 <br /> employ any person in such manner as to become subject to workman's compensation laws of Csl4ornia." Contractor's hiring or sub-contracting 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 Iowa of California." i I <br /> The appitcant m st callfor I required inspecI Complete drawing on reverse side. <br /> ' �L Date: / .Z _ll <br /> Signed � �� Title: .. -' - <br /> I FOR DEPARTMENT USE ONLY <br /> Application Accepted by SA. Date Ares <br /> Pit or Grout Inspection by Date Final Inspection b Date/ <br /> Additional Comments: <br /> Applicant - Return all copies to:t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> ` <br /> FEE MOUNT DUE A OUNT REMITTED CA$R RECEIVED BY DATE PERMIT'NO. <br /> INFO'- <br /> EH <br /> NFO EH 13.24 MEV.I I 5) <br /> EH 0n <br />