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ADPL I CST I ON <br /> ! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 200911STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {. <br /> (Complete in Triplicate) <br /> Application is hereby made.to Sen Joaquin County for a permit t6 construct and/or install the work herein described. This <br /> application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin county Public Health services. <br /> CityLo 0`t Lot Size/Acreage <br /> Job Address <br /> O <br /> wner's Name <br /> %Z_aho� —1 12 Address <br /> Phone <br /> tactor <br /> Address License No. Phone _ <br /> OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION L7 Out -of service Weli <br /> Monitoring Well <br /> PUMP iNSTALLATtOfJ 17 <br /> SYSTEM REPAIR ElOTHER ❑ [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> t'7 Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia.Speof Well. C <br /> s. <br /> [_l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ <br /> . Type of Grout <br /> I'1 Public (_1 Other Cl Delta Depth of Grout Seal <br /> l I Irrigation Approx. ept <br /> _. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done _ <br /> Sealing Material & Depth r <br /> Well Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADOITION I I DESTRUCTION I I tNo septic system permitted if'pubGc sews[ is <br /> available within 200 feet.) '. <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> € <br /> Character of soil to a depth of 3 feet: Water table depth s �" <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PK_G: TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0' No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS II Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line �. <br /> DISPOSAL PONDS ❑ <br /> 1 hereby cenify 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 of <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance rnia." Contractor's hiring or sub contracting signature <br /> 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 Californ <br /> certifies the following: "I cenify 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 /> Thepplica ust c II for r wired spa• ns. Complete drawing on reverse side. <br /> )Signed , <br /> Title: Date' <br /> a ' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by r <br /> Date! Z rr '~` Area <br /> Pit or Grout Inspection by Date Final Inspection by e f��� Date Z <br /> t <br /> Additional Comments: <br /> e Applicant - Return all copies to: San Joaquin County Public Health Services <br /> a, 613 <br /> Environmental Health Permit/Services Yrd <br /> 445-N San Joaquin, P 0 Box 2009, Stkn, CA 95201 t/ <br /> FEE AMOUNT DUE AMOUNT REMITTED"':'V' CASH RECEIVED BY OATS PERMIT NO. <br /> INFO ,f� <br /> �) <br /> * EH 19.21[REV_1i'ni5) .l6 � w/: y'� �� <br /> f EH 1445 - -- <br />