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APPLICATION FOR PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ;. <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRE 1 YW FROM DATE ISSUED1 <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application in made in coatpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. i <br /> Job Address � Cit Lot Size/Acreage - <br /> Owner's Name 2 Address L.616r-zy /T 1x15F Phone--,1.3,2-8:U <br /> Contractor Address License No. Phone • <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER C3Monitoring Well ❑ <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 /> 0 industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrioation __.Apprax• Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material li Depth s <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION K DESTRUCTION l I lNo septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: -/— Number of bedrooms <br /> Character of soil to a depth of 3 feel:, Water table depth <br /> SEPTIC TANK. Typ4/M1-1 Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. S Length of lines 1 Total length/size <br /> FILTER BED Cl Distance to nearest: Well l t' Foundation X Property Line <br /> SEEPAGE PITS IK Depth 7�� Size / umber _— <br /> SUMPS Ll Distance to nearest: Well Foundation=1d Property Line <br /> I DISPOSAL PONDS ❑ <br /> t <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 /> Homs owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t 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 laws of California." <br /> I` The applicants ust all for all requir s s. Complete drawing on reverse side. <br /> Y <br /> Signed Title: Data: <br /> FOR DEPARTMENT USE ONLY ! <br /> Application c ted by Date Area Pr <br /> Pit Grout <br /> Inspection b - sq -f Final Inspection b Da <br /> nspec Y --<c/ <br /> ditbnal Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT*NO._ <br /> INFO /! r1y <br /> a ENt3-24NIEV.r/nsi C- <br /> ��.�v 1l t�a <br /> r EH 14-M <br />