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s <br /> ` APPLICATION FOR PERMIT <br /> PAYFWjEjVr <br /> Y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> { ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 ' ' 1992 <br /> (209) 468-3447 SAN JOAPUIrV ''OL#NTY <br /> P118LjC HE-Al-Til ,,C,?VICES <br /> PERMIT EXPIRES 1 YEAR ROM DATE ISS2EDR0NA4EN1TAL HEA.L,1'kJ CU1Vi <br /> (Complete in Triplicate) <br /> - Application is hereby made,to San Joaquin.County for a,permit t6 construct and/or install the work herein described. This <br /> <application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and'Regulations of San <br /> Joaquin Cotut,ty Public Health services. <br /> Job Address L a��I City t Size/Acreage <br /> Owner's Name 1" Address ?/�`1 W� Phone <br /> Contract AddresLicense Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION f�1' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _FOUNDA.T.ION_ ---� AGRICUL-T-URE-INEL-L-Z "^,""-`OTHER-WELD =PIT5/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ <br /> 0Indus list ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications <br /> M Public 1:1 Other 'p Deita -Depth'of Grout Seal Type of Grout <br /> i 0 Irrigation p` Approx. Depth 0 Eastern ~ rSurfice Seal Installed by <br /> ` Repair Work Done 0 Type of Pump ,�` "�H.P.' �-��-"� State Work Done J, g \ <br /> Wait Destruction ❑ Well DiameterSealing Material i Depth <br /> Depth A' Filirr`1Material aDepth <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION Ll REPAIR/AOOITION L7 DESTRUCTION CI (No septic system permitted if pubtic sewer 's <br /> I available within 200 lost.) <br /> installation will serve: Residence h! Commercial— Other r. <br /> Number of living units: Number of bedrooms <br /> w:Character of roil to a depth of 3 feet: Water table depth <br /> F SEPTIC TANK ❑ Type/Mfg Capacity f " No. Compartments <br /> PKG. TREATMENT PLT. C) <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. 8 Length of lines - Total length/size <br /> FILTER BED fl Distance yto nearest; Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Siza Number <br /> SUMPS Ll Distance to nearest:, Well Foundation. Property Line <br /> DISPOSAL PONDS © <br /> -I hereby Canify 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 cenifies the following: "I cenify 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 /> 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 /> t lion laws of California." <br /> The applicant must call for at a ired ins t' n complete drawing on revers side, / <br /> Signed Title: Date: <br /> OR DE E ONLY <br /> Application Accepted by Date "'IwlAea <br /> Pit or Grout Inspection by Date Final Inspection b Dats� <br /> Additional Comments: <br /> Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 y Y <br /> INEO AMOUNT DUE AMOUNT REMITTED / K x RECEIVED BY DA E PERMIT'N0. <br /> � H <br /> . EM 13.26 IREY,r/n5 <br /> EH 1.4.26 ` � �� � � / ' <br />