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i <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ! ENVIRONMENTAL HEALTH DIVISION P ,, <br /> 445 N SAN JOAQUIN, PHONE (209)468-34200j' ; 5 <br /> i P O BOX 2009, STOCKTON, CA 95201 SEP in , <br /> {� PERMIT EXPIRES 1 YEAR FROM DATE, . SSIIED SAN.,OAQLj1N M'JFNTY <br /> (Complete in Triplicate) r�Vvil�liil;�v;EN'AL r t <br /> HEALTH DMS10N <br /> Application is hereby rade to San Joaquin County for a 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 1$62 and the Rules and Regulations of San <br /> Joequin County Public Health services. <br /> 4 <br /> Job Address L 7 LrnnCity Lot Size/Acreage <br /> O�ner's Nam a Address {� Phone <br /> 'i _�/+_CC <br /> Contractor } Address License No.0�0 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT -n I -DESTRUCTION,❑ Out of Service Well <br /> I� PUMP INSTALLATION ❑ SYSTEM REPAIR tf OTHER O Monitoring well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I�INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Induitrial ❑ Open Bottom ° ❑ Manteca Dia. of Well Excavation Dia.'of Well Casing <br /> Domestic/Private 0 Gravel Pack° ❑ Tracy Type T r <br /> of Casing Specifications <br /> i'l IPublic 1:1 Other Mil Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I EasterA Surface Seal Installed by 1 <br /> Repsi{Work Done U Type of Pump-Sed H.P. I S Stato Work Done <br /> Well Destruction ❑ Wall Diameter LO 10 Sealing Material A Depth <br /> ► Depth hiller Naterial•i Depth �K TYPE,OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( ) DESTRUCTION 1,1 INo septic system permitted it public sewer is <br /> I ( available within 200 feet.) <br /> In'stallation'will serve: Residence— Commercial_ Other f <br /> Number of,living units: Number of bedrooms # <br /> t f 1 <br /> Character of soft to a depth of 3 foot: Water [able depth <br /> SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments <br /> PKG.'TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest:_Welt_ ;Foundation Property Line x 3 <br /> E � , <br /> LEACHING LINE ❑ No. & Length of Jines `' Total length/size <br /> FILTER BED 1 ✓»I Distance to nearest/ 1 Vsil Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to naar't: Well Foundation Property Line <br /> 1 <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, slate laws, and <br /> rubs and regulations of the San Joaquin County <br /> . _-Horne owner-or.tiesnsed agent's.signature-certifies the-following:_"I.certify-that in the performance-of-the.work-for-which,this.pormit-is-issued, 1 shall-not <br /> per employ any pin such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies <br /> the fo : '.'I Certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's companss �.-,..-- <br /> .r. tion laws nla." <br /> The appy nit call for all sell insp'c ' ns. Complete drawing on rove side. <br /> ` -- Sigma Title Date —•�e..a-..» ; <br /> LYaF R=MEUSE ONLY <br /> Application Accepted by Date17 Area ` <br /> Pit 1or Grout Inspection by Date Final Inspection by 1WE4 <br /> r Date r5J <br /> Additional Comments: <br /> I <br /> kApplicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> i� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEEk INFO AMOUNT DUE AMOUNT REMtTTEd CK RECEtVEp BY DATE `PERMIT NO. <br /> • EM1}2,tREV.It it 5) �J <br /> EH 14.28 7 <br /> __ &� <br />