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APPLICATION FOR PERI!IT Jo <br /> t . <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV IRONN HEALTH DIVISION <br /> P O BOX 2009 S TON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES X YEAR rR Id DATE IS UED <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 in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rule'1111111luad Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 2 .3d4 r, 3Z City11,04A1414Lot Size/Acreage :ZQ <br /> Owner's Name ` Address �J�J` 3 f� N�7 �J Z Phone <br /> �l <br /> t <br /> ' Contractor / Address License No. Phone <br /> f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O <br /> : PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C' Industrial/ O Open Bottom' ` O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack,. ❑ Tracy Type of Casing Specifications <br /> CI Public Cl Other O Delta Depth of Grout Seal Type of Grout <br /> CJ Irripafion­ Approx. Depth ❑ Eastern Surface Seal Installed by <br /> s. Repair Work Done U Type of Pump)I H.P. State Work Done <br /> Well Destruction O Well Diameter sealing Material i Depth <br /> r. <br /> Depth t Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/AOOITION PC DESTRUCTION M lNo septic system permitted if public sewer is <br /> e available within 00 feet.] <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms � k� f' <br /> Character of soil to a depth of 3 feet: ? / Water table depth <br /> f SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 ` Method of Disposal <br /> a <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Lengthy of lines Total length/size <br /> FILTER BED cl Distance to nearest: Well Foundation Property Line <br /> ;;SEEPAGE PITS I I Depth f Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> s e DISPOSAL PONDS . O <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 tieensed agent's signature certifies 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 mariner 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 /> alon laws of California." <br /> The applicant must call for all required inspectio s. Complete drawing on r arse side. f <br /> Signed X ',Date: <br /> FOR DEPARTMENT USE ONLY-.., <br /> Application Accepted by Date Area <br /> ' <br /> Plt or Grout Inspection by Date Final Inspection b <br /> Additional Comments ! <br /> t 4r f �. <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 4451N.:SAN JOAQUIN, P O.BOX 2000, STOCKTON, CA 85201,. -�•--.r_�,y. <br /> ov <br /> FEE AMOUNT DUE AMOUNT REMITTED � ` RECEIVED BY DATE PERMIT NO. <br /> INFO II <CA/7S/N' <br /> EH 1 4 tREV.riKei //y �� // / / /ai/ <br /> 9H ;4•le <br />