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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 /> R <br /> (Complete in Triplicate) <br /> Application Is hereby made,to Sam Joaquin County fora permit to construct and/or install the Work herein described. This <br /> application Is made in cotapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San j <br /> Joaquin County Public Health Services. <br /> i <br /> Job Address City Lot Size/Acreage <br /> i <br /> Owner's Name . F Address Phone <br /> Contractor !�' Address L License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ill Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION 0 DESTRUCTION XT (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Reaidence� Commercial Other <br /> Number of living units: _Number of bedrooms 3 <br /> Character of&oil to a depth of 3 feet: Water table dep.th <br /> SEPTIC TANK __ 0 Type/MfgCapacity �_ rt <br /> , No. Compaments <br /> PKG. TREATMENT PLT. CI - _. w Method of Disposal <br /> Distance to nee t: Well Foundation._/_a Property Line Ls <br /> � <br /> -..LEACHING LINE L4--lTo—& Length of lines To�l_length/size <br /> FILTER BED !-f""Dis�aica to nearest: W Well + Foundation'" ! <br /> '.:. Property Line„ <br /> ) <br /> SEEPAGE PITS' 11 De Size Number <br /> SUMPS I ! LDistance to nearest: Well Foundation /— - '� <br /> �� Property Lina <br /> DISPOSAL PONDS ' ❑ 1. t # <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 following: "I cahify 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 taws of California," Contrecto(s hiring or sub-contracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion is f California " <br /> The applica if .. .ins do Complete draw no ase.sidM <br /> Signed Title: <br /> Date: �r <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by .__ ,�� ►� _��...�. Date Area <br /> Pit or Grout Inspection by — ` hate Fine spection <br /> .M1 Additional Comments; <br /> Applicant - Return all copieaato-. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> INFO V AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> . <br /> 6H 13-74 IREM.I/n S! <br /> EH;f•m !der �. 1 _! �-7dW3 i <br />