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'TM t <br /> APPLICATION FOR PERMIT { <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES € <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> REMIT EXPIRES 1 YEAR gQM D,&JN..TSSUED <br /> (Complete in Triplicate) <br /> fApplication is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> r application is made in compliance with San Joaquin County Ordinance,No. 549 and 1862 and the Rules and Regulations of San <br /> i Joaquin County Public Health Services. <br /> i <br /> Lot Size/Acreage <br /> Job Address <br /> i.�." �F,t City <br /> l <br /> Owner's Name <br /> Address _ dl.,�-+�_ O Phone <br /> Cont ratfor -�S Address'' f� p icense NoPhone¢�+'��e <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION Cl Out of Service Well Ct <br /> OTHER ❑ Monitoring Well C7 <br /> PUMP INSTALLATION A SYSTEM REPAIR K <br /> DISTANCE TO NEAREST,'SEPTIC TANK' " SEWER LINES -.,DISPOSAL-FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation Dia. of Well Casing <br /> L7 Industrial D Open Bottom . 0 Manteca <br /> i 3 f <br /> f "[tDomesticIPrivate GI Gravel Pack . ❑ Traty Type of Casing Specifications <br /> ID Public 1:7 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Ci Irrigation — Appro, Depth <br /> l 0 Eastern Surface Seal installed by ! <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction D Weil Diameter Sealing Material i Depth <br /> Depth 1 .. Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INS TALLATiON fl -REPAIR/ADDITION 0 DESTRUCTION Ci (No septic system permitted if public sewer is <br /> $, available within 200 fest.I <br /> Installation will serve: Residence Commercial— Other , <br /> Number of living units: Number of bedrooms k <br /> Water <br /> Is,;: , <br /> Character of soil to a depth of 3 tae;: table depth <br /> f SEPTIC':TANK. ❑ Type/Mfg CapBCity, No. Compartments <br /> l _`,-,KG.1TREATMENT PIT.C1 �.. Method of Disposal <br /> �PE <br /> �r <br /> Distance to nearest: Well Foundation ^' - Properly Line <br /> th/size <br /> TEACHING LINE 0No. & Length of lines Total len g <br /> FILTER 8ED E-) Distanceto nearest: Well Foundation Property Line <br /> � E <br /> SEEPAGE PITS It Depth, Size Number .� <br /> SUMPS _ _ _ _ LI Distance to nearest, Well Foundation Property Line <br /> DISPOSAL PONOS �'►O��'�� <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 Sari Johquin County <br /> Home owner iicensed'agent's signature certifies the fallowing: "t certity that in the performance of the work for which this permit is issued, I shall n <br /> rot <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 /> I 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. "1 <br /> The applicant mutat call f r all regr inspsctionsr Complete drawing on re arse side. 9 , <br /> a f -. }� -- - Date: L 3 = _ <br /> I <br /> Signed Title. o <br /> F i OR DEPARTMENT USE ONLY <br /> ` Application.Acceptsd by { ` DateArea ��- <br /> Pit or Grout Inspection by Data Final Inspection by Pate <br /> t <br /> Additional Comments. - <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> j� ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE ~._AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO - <br /> FM f3.7417tEY.ilw�l 2 G r Q ..2171 <br /> EH 14-2111i V <br />