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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 i <br /> # (209) 468-3447 o <br /> ATiR1tiT UPIKES 1 YEAR_PggX..DATE ISEUED <br /> I (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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se ry ces. <br /> City ""�- Lot Site/Acreage '�`�Q� �l i <br /> Job Address OD <br /> -S <br /> Owner's Name <br /> Address «,1�'`^' r��- �- - Phone F <br /> c�I� Q�om,n,/�_ �p 1 � <br /> Address �l0 01.1C License NoC_�T ' 82& <br /> • Contractor hone � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DE TR ION ❑ Out Service Well ❑ t <br /> INSTALLATION ❑ _ __ SYSTEM REPAIR L) � I nitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD.- PROLINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications ; <br /> M Public 1-1 Other 0 Delta Depth of Grout Seal e%'2�1 Type of Grout <br /> GI Irrigation Approx.Depth ❑ Eastern Surface Seal installed by ScI' 9imeer - <br /> Repair Work Done D Type of Pump H.P, State Work Done _ <br /> Weft Destruction U Well Diameter Sealing Material 6 Depth <br /> Depth t Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTACLATION❑ REPAIR/ADDITION M DESTRUCTION 111 iNo septic system permitted if 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: f Water table depth <br /> SEPTIC TANK. 0 Type/Mfg;:1 Capacity No. Compartments <br /> PKG, TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line I <br /> / <br /> EACHING LINE L'1 No. & Length of lines Total length/size <br /> FILTER BED n Distance tonearest; Well Foundation Property Line <br /> k: <br /> S EPAGE PITS 11 Depth I Sita Number i <br /> LIMPS �l Distance to nearest: -.011Foundation 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 comity 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 I <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 /> a applica t ust cal o all required inspections. Complete drawing on eve side. <br /> l 4jr -L- <br /> gned Title: Date: <br /> a FOR DEPARTMENT E ONLY <br /> Application Accepted by Date / r �/ --r--=- <br /> Plt or Grout inspection by [[ Date r Final Inspection by e <br /> 44� <br /> R l <br /> Additional Comments: - <br /> Applicant - Return all copies, to:, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ,. IF ,'';,ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 1445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 05201 <br /> FEE AMOUNT DUE AMOUNT REwTTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO/ CASH <br /> + EH 13-24IFIEV.i/ASr <br /> EH 14.26 / <br />