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APPLICATION FOR PEIT —�cc <br /> SAN JOAQUIN COUNTY PUBLIC HE TH SERVICES �� -- <br /> ENVIRONMENTAL HEALTH DI ISIQN <br /> 445 N SAN JOAQUIN, PHONE u 9)468-3420- <br /> P O BOX 2009, STOCKTON, A 95201 <br /> ? re �/ PERMIT EXPIRES 1 YEAR FROM SATE_ ISS SUID D/t`3�1f <br /> (Complete in Triplic�te) � - <br /> Application is hereby made,to Ban Joaquin County for 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 '� a S /J- -, A /6 / y` City Lot Size/Acreage <br /> Owner's Name O /1 r Address Phone <br /> Contracts {yy�� ' /ti^" Y M� Address E7` c' icenze No- <br /> Phon <br /> TYPE OF WELL/PUMP: NEW WELL 171 WELL O <br /> WELL REPLACEMENT I'1 DESTRUCTION ut of Service Well ❑ <br /> _ PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ V� <br /> _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V\ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing It n� <br /> )II Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications V <br /> I'1 Public F1 Other 1­1 Delta Depth of Grout Seal Type of Grout (J <br /> I I Irrigation —Approx. Depth 11 Eastern ace Seal Installed by <br /> Repair Work Dori /Qj Type of Pump c <br /> _.1-61 H.P. = State Work Done <br /> Well Destruction ❑ Wall Diameter — Sealing Material L Depth �^ <br /> Depth Tiller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 IeeLl <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of wil to a depth of 3 fast: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> _ PKG. TREATMENT PLT. ❑ Method of Disposal `\p <br /> Distance to nearest: Well Foundation Property Line `1 <br /> LEACHING LINE ❑ No. 11 Length of lines Total length/size <br /> FILTER BED ❑ Distance to rearmed: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lim <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> Hone owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 /> eertifiss 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 componsa <br /> tion lasva OI Cali a." <br /> The ret must [ I for W required ' spsotions. Complete drawing on re'/�J°�/aside. <br /> Signed Title: �z���R�S Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by d� Date A,Area <br /> Ph or Grout Inspection by Final Inspection by A Dan <br /> Additional Comoents: <br /> Applicant,- Return all copies to: San Joaquin County Public Health Services <br /> �( Environmental Health Permit/Servicers <br /> ^p Ll 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 <br /> 1 X✓! FEE AMOUNT DUE A OUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. <br /> IN <br /> ER to-SE MEV.1/4 5) ` � 575 lbs 9 q 5`f �D�l <br /> SEH leas <br />