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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM 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 cott>pliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. [/ C <br /> Job Address �/�<,/�e IE:. City - Lot Size/Acreage <br /> Owner's Name _ �'" - /��y��/i Address /<�C Phone <br /> Contractor Address_ v etc <br /> License No. <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT n DESTRUCTION t of Service Well ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR D OTHER O Monitoring Well <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 /> C) Industrial D Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I Public I-1 Other 1"1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Done_ <br /> Well Destruction ! Well Diameter Sealing Material & Depth C c,,- <br /> Depth //L) /00 Tiller Material i Depth (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is / <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial _ Other \ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feel: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. b Length of lines Totai length/size <br /> FILTER BED Q Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> 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 licensed 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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> canities 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." <br /> The applicant must ce .for all equrr inspections. Complete drawing on reverse side. <br /> IF-- /v --Signed , ✓�.O`1 Title: Date: <br /> i <br /> OR D ARTMENT USE ONLY ` <br /> It k <br /> Application Accepted by ���w.T 3 Date — aA�Z-^Area <br /> Pit or Grout 1 d �J Az <br /> - <br /> Ph by Date Final Inspect' by Date _ <br /> Additlonsl Comments: - v Z 1 <br /> Applicant - Return all copies to: San Joaquin County Public Bealth Services r^"�' � <br /> Environmental health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT NO. <br /> . EM 13-24IREV.riRs1 v1 1) (,^- .n 1 / — 7,C/f A ,e D r - n _ G'+ .;; -+ <br />