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APPLICATION FOR PERMIT <br /> SAN JOAQUIN45'01UNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201• <br /> (209) 468-3447 <br /> (Complete in Triplicate) <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 compliance vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> e_msy� <br /> Job Address <br /> , <br /> „ - City / _ -__ Lot Size/Acreage <br /> Owner's Name ddress - Phone <br /> Contractor�!� "�" s AtltltkSSs icense No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL/2r WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIONX SYSTEM REPAIR 0 OTHER C Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 <br /> fl Industrial EI Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> *Domestic/Private kGraval Pack ❑ Tracy Type of Casing Specifications <br /> M Public ' Other ❑ Delta depth of Grout Seal Typ of Grout <br /> 0 lrrioation CWOApprox. Depth ❑ Eastern 5u ace Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Weil Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/AOOITION 0 DESTRUCTION CI (No septic system permitted if public sewer is � <br /> available within 200 feet.l <br /> Installation will sane: Residence— Commercial— Other <br /> Number of living unite: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PIT. Cl 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 n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I i Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 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 laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: 1 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 Cali la." <br /> The applica _ requi a. Complete drawing on reveres e. <br /> Signed Title:. JDate: <br /> je�� - - '22a ____ <br /> AFOR DEPARTMENT USE ONL <br /> Application Accepted by Date /7 Area <br /> Pit or Grout Inspection by - L-'_pate 1a/31 Final Inspection by Date ' <br /> Additional Comments: ���� a✓ �� JdG <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PEERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EK t]•241�EV.iinSr 13q � 1•j9(Gty <br /> FH i{•2a ✓ <br /> f <br />