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l <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOB 2009, STOCKTON, CA, 95201 <br /> (209) 468-3447 <br /> YEAR fROM DATE I§SUEDii <br /> (Complete in Triplicate) <br /> Application is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cearpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se ices. ! <br /> Job Address �- City Lot Sise/Acreage6Z, <br /> l <br /> Owner's Nam Address �^-- Phone <br /> II <br /> Contractor. Address a - icense No.az� Phone <br /> TYPE OF'WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 17DESTRUCTION Li Out of;iService Well Gl <br /> PUMP INSTALLATION SYSTEM REPAIR ❑= OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> tD Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing Specifications <br /> Q Public, f-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Irrigation,. ` ^,Approx. De th,. Eastern �-��` Surface Seal Installed by <br /> Repair Work Done' Type of Pump` H.P.' State Work Done <br /> Well'Destruction_ ❑ ' Well Diametei Sealing Material i Depth <br /> Depth �=Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW"INSTALLATION Ll REPAIRIADDITION M DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet.) r <br /> installation will serve: Residence— Commercial,____ Other <br /> Number of living unite Number of bedrooms <br /> Character of wit to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Typo/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L-1 No. S Length of lines Total length/size <br /> FILTER BED C] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Site r Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 followiner."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 su6vcontracting signature J <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 ompen " <br /> tion laws of Celifo r <br /> The app t must Ii for all required ins ons. C _plate-drawing on rse side. f <br /> (- <br /> Signed '� Title: 7 4 Date: <br /> .001 <br /> R D A -ONLY 1�1d <br /> ` <br /> Area e <br /> Application Accepted by Date ' <br /> Pit or Grout Inspection by --=- T-7Date Final Inspection by! _ � 1 - Date �-- <br /> Additional Comments: - <br /> - I <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES H _-N. <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 88201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK I RECEIVED BY DATE PERM17 NO. <br /> INFO �CAySrH� M `` <br /> . EH 13.24IREV.�/A5! .PP C)c) <br /> ��F^� ' 4a� �+ t-IrILIJ <br /> EH.�•m I <br />