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s APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> EMIT ES 1 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 1662 and the Rules and Regulations of San i <br /> Joaquin County Public Health Services. <br /> Job Address �D City Lot Size/Acreage <br /> Address � Phone a� 7Owner's Name <br /> Conlraclor dres No. OfflA_ i <br /> ) <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ OESTRUCTION Out of Service Well Ll <br /> PUMP INSTALLATION t SYSTEM REPAIR ❑ OTHER ❑ Monito/riin'g I ell C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK "SEWER LINES �f DISPOSAL FLD;�� PROP. LINE JZA <br /> FOUNDATION ^'.AGRICULTURE WELL OTHER WELL PITS/SUMPS 1:570 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private WGravel Pack ❑ Tracy Type of Casing )0�e� Specifications <br /> M Public �her ❑ Delta Depth of Grout Seal Type of Grout PEi <br /> M Irrigation �.7`Z Approx, Degth ❑ £asternT"Y" —Surface Seal Installed by <br /> Repair Work Done v Type of Pump ! H.P. - - State Work Done _ <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIRIADDITION M DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) �Q <br /> Installation will serve: Residence.,_.. Commercial— Other <br /> Number of living units: Number of bedrooms d <br /> Character of&oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundationi'-- Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size t <br /> FILTER BED n Distance to nearest: Well Foundation Property.Line <br /> SEEPAGE PITS 11 Depth Size - Number <br /> SUMPS EI Distance to nearest: Wolf Foundation Property Line <br /> DISPOSAL PONDS ❑ N } <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 reguialions 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: "I certify that in the performance.of the work for which this permit is issued, i shall employ persons subject to workman's companaa- <br /> tion laws of California." <br /> The applicant t II uired inspe mplele drawing on raver oft side. <br /> Signed ide' Date: /Q <br /> FOR DEPARTMENT USE ONL - <br /> Application Accepted by Date, 140 —17 —7L., Area ? ,r <br /> Pit or Grout Inspection by < Date/ Final Inspection by Date Z L7 <br /> / r <br /> Additional Comments: lU �—t - <br /> Applicant - Return all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, ,P O "HO% 2009," STOCKTON, CA 85201FEE <br /> INFO AMOUNT DUE AMOUNT REMiT1 ED ASH RRECjEIVED BY DATE C/P'ERMIT'No. <br /> . EM 13"]4 IREV.I i n 51 �e..t' �� /�� {©��/ 9 <br /> EH^,{•Ie <br /> �� -7-7 -2 <br />