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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Niter <br /> ENVIRONMENTAL HEALTH DIVISION W <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 _ 10 9 4� <br /> (Complete in Triplicate) <br /> I <br /> Application is hereby made,to Sam Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cdisplianee with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> J County Public Health Services. , ) <br /> tl�l r City Iv Lot Size/Acreage <br /> Job Address <br /> Phone <br /> Owner's Name Address <br /> �P _ <br /> G tractor �` �� Address License No. Phone <br /> TYPE OF WELL/PUMP: i$ NEW WELL C1 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C] OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES W DISPOSAL FLO. PROP. LINE <br /> FOIUNDATION AGRICULTURE_WELL OTHER WELL ' PITS/SUMPS <br /> LWork <br /> DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> } rial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> ticIPrivate Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> Z) Cl Other ❑ Delta Depth of Grout Seal Type o} Grout <br /> on Al',Approx. Depth Cl Eastern Surface Seal installed by L'i <br /> ork Done U Type of Pump H.P. State Work Done <br /> ruction OWelt Diameter Sealing Ideterial i DepthFiller )Material i DepthDepth <br /> SEPTIC WORK; REW INSTALLATION O REPAIRIADDITION M DESTRUCTION iNo septic system permitted it public sewer is <br /> II available within 200 feet.) <br /> Installation will serve: Residence Commercial •,,._ Other <br /> Number of living units: A Number of bedrooms 1 <br /> Gharsctsr of$oil to a depth.�of 3 feet: Water table depth <br /> r <br /> SEPTIC TANK. ❑ �Typs/Mfg Capacity No. Compartments f <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> �Dlstance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I rpth Sire Number <br /> SUMPS Cl tance to nearest: Well Foundation Property Line � <br /> DISPOSAL PONDS - 0 <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 county <br /> Home owner or licensed agen:fs 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 lawa 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." III <br /> The app)' a t mus call for 111jreiMorii ins.�omte drawing on reverse side. <br /> Signed Title: ., Date:0 aO"EPARTMENT USE ONLY <br /> a --moi <br /> Application Accepted by Date o Area �j �} <br /> Pit or Grout Inspection by I� Date Final Inspection by v Dateli-q v <br /> Additional Comments: — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> II 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 _ <br /> FEE PUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT'NO. <br /> INF IV -6 <br /> '7��`t/ c <br /> . EH 13.24 IREv.i,xy, T r <br /> EH un <br /> IN - <br />