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APPL I CATI& FOR PERM I T <br /> C <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PM11__EXPLREZ 1 YEAR PROM_DATE LI UM <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 ie made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County <br /> � Public Health Services. <br /> �r� <br /> Job Address gama City Lot Size/Acreage <br /> Owner's Name ZV CA- moi.. ld,G_ Address __ Phone <br /> Contractor �-�- Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well [7 <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 /> ,'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public is Other ❑ Delta Depth of Grout Seal Type of Grout <br /> C3 Irrigation —.Approx. Depth Eastern Surface Soul Installed by <br /> Repair Work Done X Type of Pump H.P, _ ' _ State Work Dona �r"f <br /> Will Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIRIADDITION M DESTRUCTION LI iNo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial— Other <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 No, Compartments <br /> PKG. TREATMENT PLT. C'1 Method of Disposal <br /> Distance to nearest: Well Foundation ".Property Line <br /> LEACHING LINE Ct No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 the following: "t certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's 4com $a• <br /> tion laws of California." <br /> The ap t call for all require 'nspectio , Cam to drawing on r e side. / <br /> Signed Title: Date:'-{ <br /> F RTMENT USE ONLY <br /> Application Accepted by Date ^ Area <br /> Pit or Grout Inspection by Date Final Inspection by ,,' �j-.sS,rr�'= Oats <br /> ;�� <br /> Additional Comments: <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 BOX 2008, STOCKTON. CA 95201 <br /> FEE <br /> INFO AMOUNT <br /> /DDUjE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13.24 1FIEV.+/1151 qS.�+� <br /> FK:1•te 4 <br />