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{ APPLICATION FOR PERIL I T" <br /> SAN JOAQUIN COUNTY PUBLIC URALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE IgSUMD <br /> (Complete in Triplicate) <br /> Apylication Is hereby mrtde,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 6 1 Go x k <br /> Job Address 7 n City ize/Acreage <br /> Iy63 <br /> XOwner's Name '7 Address ���[�L,<..�^—�� ,.r��� �� Phone(i�_ <br /> xContractor e Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. POOP. LINE i <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack7.1 ❑ Tracy Type of Casing_ Specifications <br /> 1'1 Public EI Other 1"1 Delta Depth of Grout Seal Type of Grout {� <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done 0 Type of Pump . H.P. State Work Done _ ��? <br /> Well Destruction ❑ Well Diameter '� Sealing Material a Depth <br /> Depth Filler Material i Depth <br /> s <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION [ I DESTRUCTION o septic system permitted if public sewer is <br /> Installation will serve: Residence_1.1Commerciaf_ -wipLiable within 200 feat.) <br /> _ <br /> Number of living units: Number:of bedrooms__ _ XPI <br /> Character of soil to a depth of 3 feet: ,ter to le depth <br /> SEPTIC TANK ❑ Type/Mfg {C,t17 _mya ve eY�Wl �+gpartments <br /> PKG. TREATMENT PLT.© worm ol�g mpletadIWFF g in! 0 Disposal <br /> Distance to nearest: Well oun tion r Y the <br /> LEACHING LINE L1 No. b Length of lines Total length/size j <br /> FILTER BED 0 Distance to nearest: Well --Foundation Property Line <br /> I <br /> SEEPAGE PITS I I Depth f Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O t <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 I 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 taws 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 applicent,5FUst call fo equire res-Complete drawing on reverse side. <br /> xSigned Title: x y Date: <br /> \ <br /> �FOD RTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> ( Environmental Health Permit/Services <br /> jt 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE ^i AMOUNT REMITTEDCASH RECEIVED BY DATE PERMITNO. <br /> INFO <br /> • EM 13.24 IREV,l i r S r/,j <br /> Eli 14.28 ' q5�c)o <br /> `� <br />