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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 I <br /> PEMIT EXPIRES .1 -YEAR PROM DATE ,ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby mads to San Joaquin County for a permit to construct and/or install the work herein described. This w <br /> application is made in cowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County <br /> Public <br /> Health Services. /] <br /> Job Address y � t Ii1�&e City Lot Size/Acreage V <br /> Owner's Name flaL Pd"y\ Address L //y•• � Phone -' r <br /> z <br /> Contractor lws :Zfw Address V d License No.!Phone / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPIfACEMENT n DESTRUCTION ❑ Out of Service well 0 <br /> 1k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well u <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLD, PROP, UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial 0 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public is Other M Delta Depth of Grout Seal Type of Grout t <br /> 0 Irrigation — Approx. Depth ❑ Eastern Surface Said Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Material i Depth J <br /> Depth Filler Material i Depth , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION iNo septic system permitled if public sewer is <br /> available within 200 feet.) <br /> r <br /> Installation will serve: Residence r. Commercial____, Other <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 fest: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg' '- - Capacity '"No:Coifipartrnents <br /> PKG. TREATMENT PIT, Cl Method of Disposal r <br /> Distance to nearest: Well i Foundation Property Line a <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED f_'1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number I <br /> SUMPS Li Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ j <br /> I hereby cenify 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 x <br /> Home owner or licensed agent's signature certifies the following: rl 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 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." t I <br /> The applicant mu II for all requir in pac"Pons. Complete d►ayring on revs ide'. f <br /> Signed Title - Date:' <br /> � �� <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by PAZ 'r'�'�J Date ,0 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date I f aB <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 2009, STOCKTON, CA 952011 <br /> FEE INFO AMOUNT DUE AMOU�NyT�REMITTED CASH RECEIVED By DATE PERMIT NO. <br /> • EM 13,74 IitEV.1/n Sr o0 �' nj <br /> Ell"..m 7� 1?� I` � (.J V <br />