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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR FRQH 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.ie made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. C �.G / <br /> Job Address - �f- �� , ` City✓ "`�� 2_a� Lot Size/Acreage IIX 7 . <br /> Owner's Name �" ��� Address !�L�S WN` Phone 3S �J <br /> Contractor G �S Address I� /f z License fro. / /2:37-3 Phone ��� <br /> TYPE OF WELL/ UMP: NEW WELL _ WELL REPLACEMENT DESTRUCTION ll 0 <br /> of Service We <br /> PUMP INSTALLATION_ SYSTEM REPAIR C1 OTHER p Monitoring Well [7 <br /> DISTANCE TO N AREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED US E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (� <br /> omestic/Privy e ❑ Gravel Pack, ❑ Tracy Type of Casing_ e0 ^ Specifications �/ U <br /> M Public i-1 Other ❑ Delta Depth of Grout Seal ._ 00 Type of Grout-.,Lw <br /> GI Irrigation _.,.,Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump SUff H.P. f Stat ork one_. <br /> Well Destruction ❑ Well Diameter 4 Sealing Material i Depth <br /> Depth Filler Material i1 Depth �r <br /> TYPE OF SEPTIC ORK; NEW INSTALLATION❑ REPAtR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will rye: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of $oil to a depth of 3 feel: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments y <br /> PKG. TREATMEN .PLT, 0 Method of Disposal <br /> 'Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L No. b Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL POND ❑ <br /> I hereby certify the 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulation of a San Josquin County <br /> Home owner or 1' sed ap is signature certifies the following: "I certify that in the performance of ilie work for which this permit is issued, I shall not <br /> employ any r suc nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies t f owin ; "I c ify that in the performance of rk for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion Is o Calif r <br /> The ppl' a fo 11 requi in o to dr ing L JCs side. - <br /> Sign Tide, r �f <br /> Date: <br /> -� F�OQR-DEPARTMENT USE ONLY q �7 <br /> Application Accepted by ^--�•�'"�'� Date 7 �Z l pArea !t <br /> Pit or Grout Inspection byy(1 Date 7 Ir Final Inspection by ��'`�l"�� Date 7 <br /> Additional Comments; � t� A'. O �]� I lL�/� <br /> Applicant - fleturn all Copies to: AN,JOAQUIN COUNTY PU LI HEALTH SERVICES % r"� e `� �T- <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201FEE �J <br /> ,vpv�n INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNo. <br /> EH 13.24 IREV.t i 51 lues J <br />