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APPLICATION FOR PERMIT S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 1� <br /> P O BOX 2009, STOCKTON, CA 95201 �Co <br /> (209) 468-3447 <br /> YEAR <br /> (Complete in Triplicate) <br /> Application is hereby rands to San Joaquin County for a permit to construct and/or install theiwork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public H^t�alth Services, ' / ` <br /> Job Address - T J -� ��-- hJ (2-R City Lot Sine/Acreage 11 <br /> \a .� <br /> �. Address `� -Phone <br /> Owner's Name s <br /> A Conlraclor� Address License No, Phone - <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well—Of <br /> ell ❑ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Mon oring Well <br /> DISTANCE TO NEALWEK EPTIC TANK SEWER LINES DISPOSAL FLO, LINA: <br /> FOU AGRICULTURE WELL OTHER W PITS/SUMPS <br /> INTENDED USE TYPE OF WELL M AREA CONSTRUCTIONICATIONS F <br /> industrial III Bottom ❑ Manteca ia. of xcavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy e o Specifications <br /> C=f Public I Other D Delta Depth of Grout Se Type of Grout <br /> CJ Irfioation �,.ApproKDepth astern 5tiririca Seal Installed by <br /> Repair Work Done U Typs of Pum H.P. State Work Done _ <br /> Wall Destruction © Well - star Sealing Material i Depth <br /> pth Filler Material i Depth <br /> TYPE OF SEPTI ORK: NEW INSTALLATION Cl REPAIR/ADDITION M OESTRUCTION_V iNo septic system permitted if public sewer is <br /> available within 200 feel,l f <br /> installation will serve: Residence — Commercial— Other <br /> i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PET. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth 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 California," 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 laws of California." <br /> _.�..The_applicant•must call for all required inspections, Complete drawing on reverse side. <br /> '(Signed Date: 5i- <br /> Title: --- <br /> FOR DEPARTMENT USE ONLY <br /> T _ApplicationAccepted by Date 5-3 /;.__..._Area. --- <br /> Pit or Grout U Inspection by __ Date Final Inspection by Date G +p <br /> r <br /> Additional Comments: �` 3 L I ® ' <br /> Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOR 2009, STOCKTON. CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK8 PECEIVEO By DATE PERMIT NO. <br /> INF�O �} CASH <br /> IREV.,/.0)S{'I,.J [ ©' 0b 1 i i 3 1 <br /> EN;ode <br />