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APPLICATION FOR PERMIT <br /> USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 11601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O SOX 2009, STOCKTON, CA 95201 <br /> ,11 pMWIT EXPIRES 1 YEAR FRQM DATE <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County PublicHealth Services. �1 <br /> IE t �L �. �._ City Y1 �°4ot size/Acreage <br /> Job Address - Q D -7 <br /> Owner's Name "'' I O �j Kdd,ess 1 q/ / 7 — Phone J <br /> �^ <br /> Contractor il� Address License No. Phone <br /> _ g ��-� — - <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION Cl -- SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 <br /> DISTANCE TO NEAREST: SEPTIC TAhNK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i <br /> [.l Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications <br /> I'] Public C] Other ❑ 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 U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth �I <br /> Depth II" Filler Material & Depth C� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION fF, DIESTRLICTION I I (No septic system permitted if public sewer is � <br /> II available 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 ❑ Type/Mfhg Capacity__W___ No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1. Method of Disposal <br /> Distance)to nearest: Well Foundation Property Line <br /> LEACHING LINE P''No. & Length of lines2. <br /> "©O ,' - To}tal length/size <br /> h <br />! FILTER BED CI Distancei.to nearest: Well oundation _ Property Line <br /> SEEPAGE PITS 11 Depth �M Size — Number <br /> SUMPS ► Distance to nearest: Well 'Foundation Property Line <br /> DISPOSAL PONDS Q <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 k <br /> employ any person in such manner as to become subject to workman's compensation taws 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California."f 1� 7 <br /> The applican m call.for all r u edh ins ctions. Complete drawing on reverse side. <br /> I <br /> Signed Title: Date: ) <br /> ,i <br /> I6 ENT USE ONLY <br /> f Date �� Q A a <br /> Application Accepted by <br /> Pit or Grout Inspection by I� Date Final Inspection by <br /> Additional Comments: <br /> i <br /> i Applicant — Return all copies to., San Joaquin County Public Health <br /> E Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH ` �1 <br /> ♦ EH 13-24IREV.iin5l it _ !� IS/ o 0^�1-1. <br /> EH 14.2.6 1 d Q <br />