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I APPLICATION FOR PERMIT _ <br /> I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQII IN, PHONE (209)468-34 <br /> 20 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> FA PERMIT EXPIRES 1 YEAR FRQM <br /> DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 1s hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cctspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public HealX�-Y_S�:2 <br /> viceaJob Address ✓ City (: Lot Size/Acreage <br /> �. <br /> Owner's Name AddressAgo <br /> . Phone <br /> l <br /> * Contractor Address Zicense No.f�!Phone ' <br /> ` I"- ? <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service ileal ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well G] <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 r W <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I^1 DorneaticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 1'1 Public ' _C7 Other Fl Delta Depth of Grout Seal Type of Grout <br /> I I litigation Y Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 17 Type of Pump k.P. State Work Done <br /> } Sealing Material & Depth i <br /> .Well Destruction ❑ Well Diameter � <br /> Depth Filler Material Ila Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I V REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> r available within 200 lest.) Q <br /> Installation will serve: Residence�.... Commercial_ Other , <br /> Number of living units: __L-- Number of bedrooms <br /> Character of soli to a depth of 3 feat: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> (� PKG. TREATMENT PLT.❑ Method of D' sal I <br /> i Distance to nearest: Well y_ Fgundation Property Line ---7s <br /> - I <br /> LEACHING LINE Cl No. 6-Length of lines _ Total length/size <br /> FILTER BED ❑ Distalnce to nearest: Well- 7 Foundation (p_ Pro <br /> ..._ PemS+ Lina 7 <br /> SEEPAGE PITS Ii rf O ( i <br /> Depth f%C Sise umber <br /> UMP LI• Distance to'nearest: Well/ Foundation . Property Line <br /> NSPOSAL PONOS' ❑ <br /> t° 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 end regulations of the San Joaquin County <br /> Home owner or licensed agent's signature comities the following:""I certify that in the performance of the work to►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 sui>-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 lawn of California." <br /> F The applican must call for uired inspectns. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> . - - Date <br /> LY �1 1_1 <br /> F <br /> Application Accepted by - - Date�- ! Area 1 ry <br /> a _ <br /> /,)or Grout Inspection by �!�2,an_ <br /> ate Final Ins ction by DataAdditional Comments: ,�?�1 ✓ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Envhal Health Permit/Services <br /> 445 San <br /> 445 N San Joaquin, p O Box 2009, Stkn, GA 85201 <br /> r <br /> FEE INFO AMOUNT CUE AMOUNT REMITTED CK I <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> tHuy � <br /> 'REV.tiest td d 1/`7-Ub ll�� f` 5� � � Q�1' <br />