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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 i <br /> PERMIT EXPIRES I YES—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 in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. s <br /> Job Address / City Lot Size/Acreage " <br /> j 7 - '' <br /> 0 nor's Name9QZ � * Address Phone v <br /> C r or e cen o. Phone <br /> TYPE OF WELL/PUMP: NEW WELL OU WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Weil ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP-'LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Oia. of Well Casing <br /> C) Domestic/Ptivate ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public I:1 Other 1-1 Delta f Grout Seal Typo of Grout <br /> ­4Ifrigation _Approx. Depth I I Eastern Surface ant Installed by <br /> Repair Work Done 0 Type of Pump H. State Work Done <br /> Well Destruction ❑ Well Diameter sling Ma ial i Depth / <br /> Depth lit er Material i Depth <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> - — available within 200 fast.) V 1 <br /> Installation will sena: Residence— Commercial_ Other i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity --'--7No.'C6mpartments a <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation y Property Line <br /> LEACHING LINE ❑ No. far Length of lines Total length/sire N <br /> FILTER BED ❑ Distance to nearest: -Well �; Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Propofty'Lino 'x <br /> DISPOSAL PONDS ❑ '. %� Q <br /> I hsreby 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 parformance 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 applies I r"g.:P,-VLPons. Complete drawing on revs Ee-side. ¢ ,� <br /> Signed tie: _ Date- <br /> FOR EPARTMENT USE ONLY <br /> +� r <br /> Application Accepted by _[~ r _ <br /> �;lu�`ttAww� Date `� d-" 3 Area E , <br /> Pit or Grout Inspection by > Date / Final Inspection by Date - 13 q <br /> Additiontil Comments: — <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services ti <br /> 445 N San Joaquiti, P`0 Box 2009, Stkn; ,,CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK 8 <br /> CASH RECEIVED$Y DATE PERMIT'NO. <br /> . E03324InEV:I/II51'� <br /> EH 11.20 <br /> .J I <br />