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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> I!ERMIT EXPIRES I YEAR tROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby a►�.toga,��01.aquln County for a permit to construct and/or install the work herein described. This <br /> application is made in comipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County *�iic Health Services. <br /> Job Address _—=`!-FZL_ 4 _ — Cit Lot Size/Acreage <br /> Owner's Nam Ift&e Phone <br /> Contractor Address Pn§�_1W_k*0Zftense No. �� Phone-� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONX Out of Service well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHEW❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // p <br /> F.i Indusvisl ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> G Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> r*1 Irrigation —Approx. Depth ❑ Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P. W k e <br /> Well Destruction Well Diamelat Sealing Material i Depth <br /> Depth B Filler Material i Depth— Z7 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION 0 (No septic system permitted if public sewer i <br /> 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 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED E-1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number O <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <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 Moto a subloc, to workman's compensation laws of California." Contractor's hiring Or sub-contracting signature <br /> certifies the follow' : "I certify that in a oem%nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cal' <br /> The applicant ' I or all re s ns. Com <br /> �lots drawing on reverse side. <br /> Sign ' �� <br /> Title: Date• <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ea 1 <br /> Pit or Grout Inspection by Date Finsf Inspection by Dat <br /> Additional Comments: l <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 SOX 2008, STOCKTON, CA 85201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> . EH 13-24 1 REV.I/A$? b <br /> EH;{.2e <br />