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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM- DATE ISSUED <br /> (Complete in Triplicate) f <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cotplianc vi hRuin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health �° <br /> Job Address Y City Lot Size/Acreage <br /> Owner's Name _ Address d ++ Phone <br /> —336 <br /> J �.� <br /> Conirat��� _AddreA90 �(e License N Phon 5 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <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 /> L7 <br /> Ind 1 ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Z=amestic/private Ci Gravel Pack7 L1 Tracy Type of Casing_ Specifications <br /> 1'1 Public I:1 Other nDelta'"" Depth of Grout Seal Type of Grout <br /> I I Irrigation /_Approx. Depth t I Eastern i Surface Seal Installed by <br /> Repair Work Done ffl Type of Pump H.P. _ State Work Done VIA=AA�l <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet: Water table depth } <br /> SEPTIC TANK. O Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. i Length of lines Total length/size <br /> FILTER BED ❑ Distance to rarest: Well Foundation Property Line <br /> SEEPAGE PITS T I I 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 Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I comity that in the performance of the work for which this permit is issued, 1 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 lacus of California." <br /> The applicant mu 91 required I tions. Complete drawing o verse side, <br /> Signed Title: .._._. Date: - 2-- <br /> FOR <br /> 'FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3 A— <br /> Pit or Grout Inspection by Date Final Inspection b Dats <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO A�M/OUNT DUE- `AMOUNTREMITTED CK If I RECEIVED BY DATE PERMITNO. <br /> • EH1s•:WlttEY.r/ariaCH 14W 14 cl,j ov Vs, <br /> '0-0 3 8�a 3AA3 76'6 067 <br /> A <br />