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- <br /> APPLICATION FOR PERMIT <br /> t ?, SAf JOAQU I N COUNTY PUBLIC- HEALTH SERVICES <br /> ' Y e , '"'"„_�'•'�'. ENVIRONMENTAL HEALTH DIVISION <br /> 'C,O BOX 2009, STOCKTON, CA 95201 <br /> (209) .468-3447 <br /> ISSULP <br /> . (Complete in Triplicate) <br /> C i'!isil�l��•1 i:'`f-i;!-1�sf i''f' `-�i'l r.?"i 6I-:r <br /> Application 1a hereby made to Sela`Soaquin'°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 Services. <br /> Job Address,- City t 81ze/Acreage <br /> owner's Nem ^' Address Phone <br /> M <br /> • Conlrac ` � re��^fl��:��� ����tcefise No. Phon ^��` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION U1____ SYSTEM REPAIR OTHER '0 Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS •,� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Ind al•- E-) openBottom ❑'Manteca 'Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Pfivate 0 Gravel Pack C1-Tracy Type of Casing Specifications <br /> M Public T.1 Other. _❑ Delta Depth of Grout Seal Type of Grout <br /> C irrigation Approx. Depth Eastern g Surface Soul Installed by <br /> Repair Work Done 10 Type of Pump, H.P-2; _ State Work Done <br /> Well Destruction ❑ Well Diameter: Sealing Material i Depth ` <br /> Depth Filler Material 4 Depth ]�y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L_J REPAIR/AOOITfON 0 DESTRUCTION lrl (No septic system permitted it public sewer is <br /> available within 200 feet.) �►vf <br /> Installation vWN serve: Residence Commercial_ Other <br /> Number of living units: Numtier of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity Nor Compartments <br /> PKG, TREATMENT PLT. 0 f1 <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines Total longth/size” <br /> FILTER BED CI Distance to nearest: Well Foundation 'Property Line <br /> SEEPAGE PITS 11 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 dons in accordance with San Joaquin County ordinances, state laws, and <br /> rules and rrguiations of the Sen Joaquin County <br /> Home owns(or licensed agony:signature certifies the following: "I certify that in the performance of the work fdr which this permit is issued, I shelf not <br /> employ any person in such manner as to become subject to workrnan's compensation laws of California." Contractor's hiring or sub-contracting signatura <br /> certifies the following: "I cenify 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 /> The applicant mus f for all required - ".coons. Complete drawing on r rse side. <br /> Signed Title- -7 �- <br /> •���- _. Date: ! <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by -��-�-- Date f Areae' <br /> Pit or Grout Inspection by Date--,Final Inspection by Date-� <br /> Additional Comments: <br /> Applicant - Return ell 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 95201 <br /> EEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT NO. <br /> INf O <br /> 21 V0 <br /> EN A. j'EH mJ- t ! <br /> JAG <br /> 2 3f� <br />