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APPLICATION FOR PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> t P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT,.EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> f Application is hereby made.to San;Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application Is made in coWliance vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> I <br /> Owner's Name _ Address-.--- _ "-Phone. <br /> Contractor Address License No Phone- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C'1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ IAonitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ( t `FOUNDATION, "�'-_—�­.AGRICULTURE WELL OTHER WELL ' PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca - Dia. of Well Excavation Dia. of Well Casing_ <br /> n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'] Public ��.(.i Other f1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done /' t3 <br /> Well Destruction ❑ Well Diameter " Sealing Material L Depth <br /> UJ� Depth Iriller-Mlnterial >R Depth - },- VM <br /> Q <br /> .TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I 1 DESTRUCTION [ I (No septic system permitted it public sewer is <br /> available within 200 feet.) �+ <br /> Installation will serve: +Residence- Commercial Z Other .46-15 <br /> Number of living units: Number of bedrooms - <br /> Character of soil 6 a depth of 3.fesie: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity. �I No: Compartments <br /> PKG. TREATMENT•PLT.❑ Method of-Disposal <br /> .w Distance to nearest: Well 5�! t Foundati o Property Line r E <br /> LEACHING LINE Cid Mo:'A Length of lines, Total length/size <br /> FILTER BED t ❑ Distance to nearest; � .VllellFoundlrtionProperty Lina h�`/-T <br /> SEEPAGE PITS} It Depth Size Number <br /> SUMPS LI Distance to,nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑, J^ <br /> I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 <br /> rules and regulations of the Sen Joaquip County .¢ � ,I <br /> Hama 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 comper a ion taws of California.. Gontractor's hiring or sub-contracting signature } <br /> certifies the following: "I'cenify that in'the paAormanca of the work for which this permit is issued, i shall employ persons-subject to_#?rkman's compensa <br /> tion laws of California." <br /> The applicant must call for I requ'ad inspections:Completadrawing on r arse F <br /> 1. '_ <br /> Signed `"' Title Dale.- <br /> FOR <br /> ate:OR DEPARTMENT USE ONLY rt <br /> � r <br /> Application Act aptttd by Oats `�Z Area Z <br /> i ! Lk <br /> PN r G t�Ina" do by Date r� Final Inspection b' Date <br /> i Wt/ <br /> Additional Comments: <br /> �' ^ <br /> Applicant't- Return all copies to: San Joaquinott-nty ub <br /> P11c'pHeaith S rvices - <br /> Sttvi•rodmintal Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE'INFO~ AMOUNT DUE AMOUNT REMITTED F CASH RECEIVED BY OATS PERMIT'ND. <br /> . EM 1 •31 IREV.r i e sl �� [ 4 a� f I� • " - 373 <br /> EH N•2tV <br />