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APPLICATION FOR PERMIT E LS <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 N <br /> YEAR ,,� , <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cocipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Ijr. V. City Lot Size/Acreage <br /> )Job Address <br /> Kwner's Name Address Address 4Phone <br /> tractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service ti✓ell C1 <br /> PUMP lNSTALL.ATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA '\CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public f-1 Other ❑ Delta Depth of Grout Seat Type of Grout <br /> - <br /> 0 lnigauon Approx. Depth 0 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 Ir Depth <br /> Depth Filler Material tk Depth <br /> TYPE OF-SEPTIC WORK: NEWINSTALLATION D REPAIR/AODITION 0 DESTRUCTION (No septic system permitted if public sewer is' <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 . Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Cl Method of Disposalle <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. il, Length of lines` Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 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 t0 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 /> tion laws of California." <br /> The applicantmustt ca i fob ell required in pections, Complete drawing on reverse side'. <br /> Ksigned X,L /I Title: Date: <br /> I R DE ARTMENT USE ONLY <br /> : 1 O Area <br /> Application Accepted by Date <br /> 1 Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: _ <br /> Applicant -,Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2409, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REM,TTEO CASH RECEIVED BY DATE PERMIT NO. <br /> (H;4n <br />