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APPLICATION -FOR PERMIT �0c lo" _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUM., PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES : YEAR FROM DATE ISSUED. <br /> (Complete' in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit/ i construct and/or install the work herein described. This <br /> application is made in cotpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San t <br /> Joaquin County Public Health Services. _. <br /> D ✓ <br /> Job Address hd i City. Lot Size/Acreage <br /> Owner's Name Address Phone <br /> l <br /> . ,i t � <br /> Conhactor ress tl, ,4 No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ <br /> k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION 1P AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation __ Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 11 Public ,�^ n Other n Delta Depth of Grout Seal Type of Grout Q <br /> I I Irrigation . - Approx. Depth I I Eastern Surface Seal Installed by p <br /> Repair Work Done. U Type of Pump H.P. State Work Done r <br /> + Sealing Material i Depth <br /> Well Destruction ❑ -Welt Diameter - <br /> Depth` Filler Naterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l TRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) t�rO <br /> Installation will serve: ' Residence'L�Commercial Other !V f <br /> Number of living unit: Number of 9, <br /> 0ms <br /> Character of soll to a depth of 3 feet: v - Water table depth y <br /> SEPTIC TANK 1 ❑ Typ*/Wf§ �� CapacityNo. Compartments <br /> PKG. TREATMENT PLT.Ll # \ Method of Disposal i <br /> Distance to nearest:% Well F.oundalion Property Line..; <br /> 5 -- - <br /> LEACHING LINE D-446-& Length of lines To a�length/size ' <br /> FILTER BED ❑ Distance to_nearest:T.,�._We114� Foundation # Property Line <br /> SEEPAGE PITS Size NNurber <br /> SUMPS LI Distance to nearest: Wel, Foundation�' Property LineI f2 <br /> DISP05AL PONDS ❑ �' I j <br /> I hereby certify that I have prepared this application and that the work will be done in accordance•v ikh San Joaquin county ordinances, state laws, and r <br /> rules and regulations of the Sen Joaquin. County r \ <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, 1 shall not <br /> ` .J <br /> E employ any person in such manner as to become subject to workman's compensation;4ws of California:"Contractor's hiring or sub contracting signature .A <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 /> of Califtx <br /> The applic u t call for an uir s t Com eta drawing on fee sid <br /> Title: Date: <br /> f <br /> FlafPARTMENT USE ONLY... <br /> IA— <br /> Application Accepted by Data Area <br /> ,�7. . <br /> _ .:I�j <br /> flit Gioui Inapectbn by Date Frnil Inspection by `% ` Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> 4 F Environmental Health Permit/Services p <br />` FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO 2 2. �j+/� If <br /> f EN 13-24 EM Ilse(REV.I/M 5) " - 6`c �i�/ '�+ y <br />�- t <br />