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f • <br /> APPLICATION FOR PERMIT <br /> t <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 /> k <br /> PMIT EXPIRES I YEAR FROM DATE ISSUED ` <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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San t <br /> Joaquin County Public Health Services. �'�n c, <br /> f� / Lot Size/Acreage <br /> Job Address City <br /> Owner's Name <br /> 5LtS A 0 SAkE L�, Address��� 3� - Phone -5-Vo 7 ' <br /> 1-/50 0 r PIZ67A IV-r V.0,3 phone <br /> Contractor Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION m�-- SYSTEM REPAIR O OTHER ❑ <br /> Monitoring well [3 N <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 /> L1 Industrial ❑ Open Bottom C3 Manteca Dia- of Well Excavation <br /> C+�mDia. of Wall Casing <br /> estic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I1 Public l-1 Other n Delta Depth of Grout Seal Type of Grout_ <br /> I I Irrigation —.Approx. Depth t I Eastern Surface Soul Installed by 1 �� <br /> Repair Work Done 0 Type of Pump �SuQ H.P. State Work Done <br /> Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter <br /> Tiller Material Z Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 feet: Water table depth j <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKC. TREATMENT PLT.GMethod of Disposal <br /> •4. <br /> Distance to nearest; Welt Foundation Property Line <br /> LEACHING LINE 0 No. 6 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line w „ <br /> I r <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line f <br /> DISPOSAL PONDS <br /> I 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 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 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 applicant must call for alt required inspection Complete drawing on rse s• a. <br /> I Tide: Date: 3 <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ►""t� '^'�"��t 'r Date Area <br /> Ph or Grout Inspection b Date Final Inspection by Data <br /> I Additional Comments: <br /> f <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> l Environmental Health Permit/Services <br /> i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> BY DATE PERMIT-N0. <br /> INFO <br /> 5 <br /> + . EN 43.24 IIIEV,t In sl l 3- <br /> EM 14.26 ! <br />