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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 1lP O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISS19M � <br /> 11 (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct acrd/or install the work herein described. This ; <br /> application is made in coatpliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Bervi es. <br /> C � {� (� £ City Lot Size/Acreage <br /> Job Address <br /> Owner's Name <br /> • ! Address Phone <br /> � , <br /> Contractor Address License No. 0 Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT El DESTRUCTION LI but of Service We11 <br /> SYSTEM REPAIR OTHER ❑ lilonitoring Well ❑ <br /> PUMP INSTALLATION ❑ 7 r; -y, � <br /> DISTANCE TO NEAREST: SEPTIC TANK a SEWER LINES DISPOSAL FLO. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> Cl <br /> Industrial D Open Bottom ©:Manteca Dia- of Well Excavation Dia- of Well Casing i <br /> ,on <br /> t~',P❑ Gravel Pack ❑Tracy Type of Casing_ Specifications <br /> i'I Public f7] Other + 1'1 Delta Depth of Grout Seal Type of Grout <br /> i <br /> 1 1 Irrigation a`—�Appi`01% Dept IJ;Eastern $yrrface Saul Installed by I <br /> Repair Work Done U Type of Pump �`]] �� H.P. l rJ/�4 __ State Work Done <br /> Well Destruction ❑*.Well Diameter <br /> ` '/'. Sealing Material i Depth <br /> Depth'a^ r Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION 1 1 iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation,_will Commercial^-Other <br /> Number-of`lMnq units: Number of bedrooms <br /> Character of sols to a depth of 3 feet: � Water table depth <br /> SEPTIC TANK. p Type/Mfg Capacity No. Compartments <br /> PK6 "TREA-TMENT'PL'T:CI" Method of DW <br /> k ENT <br /> Distance to nearest: Well'"' Foundation Property Line ��E <br /> 'r <br /> s <br /> LEACHING LINE Cl No. m Length of lines Total length/size AUG-1 <br /> FILTER BED D Distance to nearest: Well. Foundation - Property Lina¢as nim i COUNTY <br /> 1 — s —.A ^ C <br /> SEEPAGE PITS I I Depth _ Size' <br /> ENVfRONME�VT L �TH DlViSION <br /> Il SUMPS Ll Distance to nearest: Well - Foundation Property Line r <br /> I DISPOSAL PONDS ❑ ` <br /> III '� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San-Joaquin county Pr inances, slits laws, and <br /> i rules and regulations of the Sen Joaquin County <br /> Horne ge <br /> e owner or licensed ant's signature certifies the following: "I certify that in the performCnce of the work far which ng 6r permb,t Is issued, I shall not <br /> employ any person�jan such manner as to become subject to workman's compensation laws of California," Contractor's hiring pr subcontracting signature <br /> certifies the foNowfnq:)"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 oOf It <br /> The applic s call for all req?@id inapoe:cj <br /> j0ps. Complete drawing on rev rse side. <br /> Signed Title: Date: <br /> i FOR DEPART T USE ONLY <br /> M Application Accepted by Date Area <br /> i /1011- 2-111 9't- <br /> Ph or Grout Inspection by I Date ' Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin Cbunty Public Health Services <br /> t 8nvironmentaV Health Permit/Services <br /> 445 N San Joaquin, P ox 2009, Stkn, CA 95201 <br /> EEE I <br /> INFO AMOUNT DUE AM UNT REMITTED Ash RECEIVED BY {SATE PERMIT'N0. <br /> fm t4-M <br />