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4' <br /> APPLICATION FOR PERMIT <br /> ,. , 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ( Y R <br /> PC, ke ecLc� (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 coewliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. � � <br /> Job Address � City I �"Q"�t Size/Acreage <br /> Owner's Name Addresses Phone <br /> Caniracto Address k- A— L+cense No � Phone ;L"r <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION 0 SYSTEM REPAIROTHER ❑ Monitoring Well 0 <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 /> Cl Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 15y}+Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public I"1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation N Approx. Depth ❑ a eZH.PSurface Seal Installed by <br /> Repair Work Done Qr Type of Pump . State Work Done <br /> Well Destruction Cl Well Diameter Sealing laterial i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION Ll DESTRUCTION Cl INa septic system permitted if public sewer is O <br /> available within 200 foot.) .� <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 1 . O Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to rarest: .. Well Foundation Property Line <br /> SEEPAGE PITS I'I &apth Size Number —` <br /> SUMPS LI. Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 to become subject to workman's compensation laws of California." Contractor's hiring of subcontracting 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'stom ensa- <br /> tion laws of California." <br /> The applies u call for all required ' ctio . Complete drawing ommrm,4e side. <br /> Signed Title: J - -- Date: <br /> DEPARTMENT USE ONLY [ <br /> Application Accepted by . $ „� Date <br /> ` � © Area <br /> Pit or Grout Inspection by Date Final Inspection by e Data <br /> Additional Comments: T <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 2009, STOCKTON, CA 85201 <br /> IEEE AMOUNT DUE AMOUNT REMITTED [ASH RECEIVED BY HATE PERMIT NO. <br /> . EH 13.24(REV.Irst5l <br /> EH"4.31 ctJ tJ <br /> L <br />