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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NOS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201. <br /> (209) 468-3447 <br /> YEAR OHM 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 County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin CountyPublicHealth 8e ices. !!�� <br /> Job Addre 8 City �ot Size/Acreage Off[a Ac+tt'� <br /> Owner'si4ims 5AM TAAddress Phone <br /> Contra rk-A2S31-Address. nee No �Phone <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT M DESTRUCTION ❑ Out•of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,w DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL �'.PR09LEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial a Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing j <br /> U Domestic/Private C1 Gravel Pack C1-Tracy Type of Casing s Specifications <br /> R Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ation <br /> 0 Irri A f , ' � ** <br /> U — ppror<. Depth ❑•Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump <br /> H.P. State Work Done <br /> Well Destruction C3 Well Diameter - Sealing Material i Depth <br /> Depth } Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION 0 REPAIR/ADDITION C1 DESTRUCTION WWINo septic system permitted if public sews( is <br /> available within 210 feet.) } <br /> Installation will serve: Residence^ Commerolal✓ Other.� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth d <br /> SEPTIC TANK ❑ Type/Mfg ! Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 .' Method of Disposal <br /> Pi stance nearest: Well Foundation Property Line <br /> LEACHING LINE 0'No. & Length of lines - "" Notal length/size <br /> FILTER BED 0) Distance to nearest: Well Foundation Property Line 1 <br /> SEEPAGE PITS E i"I !•Depth Site y <br /> Number <br /> SUMPS f Li^Distance to nearest: Well Foundation 0"' Property Line <br /> DISPOSAL PONDS C} t <br /> I hereby comity that I have prepared this application and that the work will be dorie in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County 6 ' <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the periormJnce of theworkfor which this permit is issued, I shall not l <br /> emplpy any r on in such manner as to become subject to workman's compensation laws of California."(Contractor's hiring or sub-connecting signature <br /> Certifies th f 11 wing: "I certify that' e performance of the work for which this permit is issued, I shall employ persona subject to wor an's compen <br /> tion laws ifornle." <br /> an ustJ2dLcal! or al ired inspec ions. Co p e drawin i- <br /> f <br /> e'an Title: ' <br /> Date: <br /> F R D T NT USE ONLY tt <br /> Application Accepted b . Date _1 Area LI <br /> Pit or Grout Inspection by . .. I Date :/Final inspection by Data [6 16 <br /> m <br /> Additional Coments; <br /> I <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 98201 e <br /> FEE OUNT DUE AMOUNT REMITTED r GK_ RECEEVE0 8Y DATE PERMIT NO, <br /> INFO CASH <br /> . CHt7.74IREV.! . pU[ r 71�1 �Gq7c) <br /> � + <br /> 41.20 <br />