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APP1rICATLQN..PbR PERMIT <br /> SAN JOAQUIN, COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p 0 SOS 2009, STOCKTON, CA 95201 <br /> R (209) 468-3447 <br /> PC- R <br /> DATE ISUTITM <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 j <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Lot Size/Acreage <br /> Job Address j2 <br /> City <br /> Phone <br /> Owner's Name Address <br /> phone <br /> Contractor <br /> Contractor d�L Address License No. <br /> TYPE WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out M ServiceonitoringWell <br /> Cl <br /> OF ell L7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> CY <br /> OTHER ❑ M <br /> #; DISPOSAL FLU. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL I 4OTHER WELL pI751SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> f_l Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Specifications <br /> kMomesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> M Public " , Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> m Irrigation " t, �.Approx, D�� E.astern­ ."'Surface Seal Installed by RL­57— <br /> Repair <br /> State Wark Done �'Ii.P.Repair Work Done '* Type of Pump. --� f <br /> �. .• _.�. SeA11ng Material <br /> Wall Destruction.— ❑-._ Well_Diameter._-._..,�.: Biller Materiel i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION >ri DESTRUCTION Ck {No septic system permitted if public Sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial-_.. Other <br /> Number of living unite: Number of Rbedrooms s <br /> Character of soil to a depth.of 3 feet: Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,0 Method of Disposal <br /> s. ^ <br /> Distance tnearest;,� Well " Foundation Property Line tl <br /> I` LEACHING LINE Cl No-&:Length.of lines ` °� Total length/size <br /> FILTER BED Fl Distance to nearest: Well a Foundation Property Line (L <br /> SEEPAGE PITS l I Depth Sue Number �✓ <br /> SUMPS Ll 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 lot which this permit is issued, I shall not <br /> i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> eertities ii <br /> he following: "I cenify that in the perlormance of Lha work for which this permit is issued, I shall employ persons subject to workman' compensa- <br /> tion lawof California." <br /> The ap cal}for all requir pt! Complete drawing on side. <br /> Signed Title: ��� Date: l <br /> F0 DEPARTMENT USE ONLY q, <br /> Application Accepted by Date " ren <br /> p _ <br /> Pit 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 DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> K I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE AERMIT NO. <br /> INFO ^n a LC( �Q <br /> EK;�.� <br />