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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 't <br /> ENVIRONMENTAL HEALTH DIVISION ' <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> l.EEI[IT EXPIRES 1 YE1 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 Count Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> ` <br /> S /p1,.,f C.1 _ City�' ��gl-- Lot 31ze/Acreage <br /> 07 <br /> Job Address <br /> Owner's Name r <br /> Address Phone <br /> S Ad <br /> dress s Q / cense No. Phone <br /> Contractor WA <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION o Out ofservice WMonitorell C7 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER CJ <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 Dia of Well Casing �l <br /> Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation _ _ `V <br /> Casing_ Specifications- <br /> C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type <br /> Type of Grout <br /> I"1 Public C7 Other -1 1' F1 Delta Depth of Grout Seal <br /> I l irrigation <br /> Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done�. <br /> Woo Destruction O Wall Diameter,. <br /> Sealing Material i Depth <br /> ! Filler Material 164iepth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION U`I,jbL0.aeprtc:system permitted if publiCsewer is <br /> 3 available within 200 feet.) <br /> f E <br /> Instsllation will serve: Residence��ommercial— Other t , <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Watei table depth r <br /> I No. Compartments # <br /> SEPTIC TANK. ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT.Gl f Method of Disposal <br /> Distance toearest: Well _F.oundation- properiy Lina <br /> + ei <br /> th/ <br /> l length/size <br /> sz <br /> LEACHING LINE Ll No. P4 Length of lines Totae <br /> FILTER BED ❑ Distance toynearest. Well Foundation Property Line <br /> SEEPAGE PITS I ) Depth - j f r Sixe <br /> s Number w <br /> SUMPS L1 Distance toy nearest: Well ! Foundation Property Line <br /> 11 1 rf <br /> DISPOSAL PONDS C3 <br /> at the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> I hereby certify that I have prepared this;application and th <br /> rules and regulations of the San Joaquin County i <br /> Home owner or licensed agent's signature cartifies 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:"I csnify that in the performance of the work for which this permit 1s Issued, l shall employ persons subject to workman's compensa <br /> ti". "we of California." <br /> The applicslr atw ,call Balt raquirad spsct' s. plate drawing on reverse si a. <br /> - Date: <br /> Sip Title: t <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by _ dam. n�! - Date <br /> y Z� Area <br /> """Pit o►Grout E'nspactbn by Date I inil inspection by Date/ <br /> I <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services -� <br /> 445-N-San.-Joaquin-,- P-G-Box}2009c .-r <br /> -StknCA-95201 <br /> FEE " CK EIVED BY ATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> . EH 1324 IREV,1/R 5) <br /> EH 14.20 C/ <br />