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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> RAMIT R PROM DATE IS5VED <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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health a ces. <br /> .LA) = City <br /> .fob AddressQi. Dt 10 — Size/Acreage <br /> 7( e� Y <br /> 1 Owner's NomeK �..,,.�.W' . ..� ,..._ Addr�ssY cM 0 �- Phone <br /> ContractorAddress License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well Gl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LlI OTHER ❑ Monitoring Well C7 <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 /> * Industrial ! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing # Specifications <br /> Q Public 1-1 Other ❑ Delta Depth of Grout Seat Type of Grout <br /> 0 Irrigation i .—,Approx. Depth ❑ Eastern Surface Seal Installed by � <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material i Depth t <br /> Depth Filler Material i Depth ) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION C7 DESTRUCTION INo septic system permitted if public sewer is <br /> r available within 200 feet.) .4 <br /> Installation will serve: Residence_ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depot of 3 feet: ' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity = No. Compartments <br /> PKG. TREATMENT PLT, C} ' Method of Disposal <br /> Distance to nearest: Well <br /> .Foundation Property Line <br /> � M <br /> LEACHING LINE L'1 No. & Length of lines Total length/size a <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS[ ❑ <br /> I hereby certify that I have prepared this application and that the work wilt 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 taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: ")certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> Ilon laws of California." b. <br /> The appl__ n s r for all e r ct' s. Complete drawing on verse side. <br /> R r r 1'� Cl "�0 <br /> Signed Title, Date: <br /> FOR PART T USE ONLYI Z — <br /> , <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by �"" '" Date Final Inspection b,;7- Date <br /> Additional Comments; 00 <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HRA TH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> INFO <br /> FEE .AA/MMOUNTTDDUE <br /> � AMOUNT REMITTED CASH RECEIVED BY y DATE /} un�PEERM17 NO. <br /> . EH 13-24 tREV.IiK5l <br /> EN 4�.2e <br />