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APPLICATION FOR PERMIT NO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �><, QL�zj <br /> ^' • ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201rA <br /> ' � <br /> (209) 468--3447 <br /> YEAR <br /> ( (Complete in Triplicate) <br /> Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is me4e in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> ISa�� ;3 �1 V City Tl� Lot Size/Acreage <br /> wner's Name Y � f — Address Phone <br /> V <br /> VContrattor ems" -L� Address License No. r� Phone <br /> r <br /> TYPE OF WELL/PUMP: EVI+ W�01 <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ Out ice well L <br /> PUMP INSTAL ! SYSTEM REPAIR C] ❑ Monitoring Well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK4EWER LINES D FLD, PROP, LINE <br /> FOUNDATION� �" � ` `AGR URE WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A O GTlON SPECIFICATIONS <br /> I <br /> i7 Industrial El Open Bottom eco" Dia. of Wel! anon Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pac t ❑ Tracy Type of Casing_ Specifications <br /> i Public !-1 ❑ Delta Depth of Grout Seal _ Type of Grout v <br /> CJ Inioation Approx, Dipth 0 Eastern Surface Seal Installed by <br /> Repair. one 0 Type of Pump H.R. State Work Done _ Q' <br /> e! Destruction C) Well Diameter ) Sealing Material 8 Depth <br /> Depth Filler`Material & Depth <br /> TYPE Of SEPTIC WORK: NEW"INSTALIATION 17 REPAIR/ADDITION ZI DESTRUCTION (No septic system permitted if public sewer is <br /> it available within 200 feet.) <br /> Installation will serve: - Residence— !Commercial_ Other - <br /> Number of living units: Numberlof bedrooms f <br /> Character of#oil to a depth of'3 feet: t Water table depth <br /> SEPTIC TANK 0 Type/Mfg � - .- Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> .t <br /> LEACHING LINE D No. & Length of lines Total length/size + <br /> FILTER BED n Distance to nearest: Well Foundation Property Line i <br /> SEEPAGE PITS I I Depth Sire Number ^ <br /> SUMPS - CI. .Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 X <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 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 this 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." I <br /> The applicant must call for all equired inspections. Complete drawing on reverse side. <br /> Signed X_ -/` / ' Title: - --- - - Dater 'E <br /> FOR DEPARTMENT USE ONLY q q <br /> ,Application Accepted by „� �r��—,- - Date <br /> 1 1 1 Area <br /> Pit of Grout Inspection by Date Final.Inspection by Data 3 <br /> Additional Comments: - I <br /> Applicant - Return al.l copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 11 <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 448 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 96201 <br /> FEE AMOUNT DUE ! AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT'NO. <br /> INFO <br /> J f I <br /> EH t{•� <br />