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APPLICATION FOR PERM I T <br /> s SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �,�� ] <br /> ENVIRONMENTAL HEALTH DIVISION � �V" " <br /> 5 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCSTON, CA 95201 <br /> {PERMIT EXPIRES 1 YEAR FROM DATE 138UED <br /> Ile` (Complete in Triplicate) <br /> r Application is hereby made to S Joaquin County for a permit to construct and/or install the vont herein described. This <br /> application is made in Compliance vith San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County public Health Services. <br /> ' r City Lot Size/Acreage <br /> 1 Job Address ' t <br /> rV1 Address 4507 <br /> Phone <br /> Owner's Name <br /> Contractor rMrlAddress a) License No,4 Phone <br /> TYPE OF WELL/PUMP: NEW WELL 13WELL REPLACE n DESTRUCTION ❑ Out of Service Nell ❑ <br /> OTHER ❑ Monitoring well <br /> PUMP INSTALLATION 0 SYSTEM REPAIR <br /> ❑ <br /> . DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of West Excavation Specifications <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ R <br /> 1'1 Public <br /> (-1 Other , n Delta 'Depth of Grout Seal Type of Grout <br /> l I Irrioation —Approx. Depth .I 1 Eastern Surface Soul Installed by <br /> i Repair Work Done Ll Type of Pump y H.P. State Work Dona_ <br /> Sealing Material Depth <br /> Well Destruction ❑ Well Diameter <br /> Ta i <br /> Depth Tiller Materiali Depth <br /> rC system <br /> k TYPE OF SEPTIC WORK: NEW INS�TALLA�TION I REPAIR/ADDITION DESTRUCTION 1 I available�wthin 200 feett;ad it public sewer is <br /> Installation will serve: R nee commercial Other. � <br /> Number of living units: Number of bedrooms <br /> C Water table depth , <br /> j Character of soli to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg f. spacity ..No. Compartments I� ? <br /> I PKG. TREATMENT PLT.❑ Method of Disposal <br /> et <br /> Distance to nearest: Well Foundation Property line <br /> t LEACHING LINE Na, b Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I I Depth,.t Size Number <br /> SUMPS r. Ll Distance to nearest: Well Foundation Property Lino <br /> DISPOSAL PONDS ❑ <br /> f n Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sa <br /> b . <br /> r rules and regulations of the Sen 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 /> 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 compansa- <br /> I tion laws of Califomia." <br /> k The applic at cal for all required inspectio pl@ta tawing on reverse side. <br /> o Da �•�i J <br /> Sig Title: <br /> � Fp D ENT USE ONLY <br /> Application Accepted by (?� <br /> Date Area <br /> r Date Final Inspection by Date <br /> � Pit or Grout Inspection by <br /> Additional Comments: <br /> y Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKS CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> • EHt3•21(REV.t i w 51q2vLc <br /> EM 14.20 <br />