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APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> FERMIRES_1 YEAR FROM DAIS ISSUED <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 Public Health Services. <br /> Job Address ! "1 C � �' City _Nl r_ Cb#: Size/Acreage <br /> P�N " L / <br /> r7 r Address ' l O Phone �ff <br /> Owner's NameD4. <br /> ! <br /> Contractor S�_L i� 9P Address License No. Phone 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service.Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public 1-1 Other I 1-1 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 L3 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material &.Depth <br /> Depth it Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIRIADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is Q <br /> i� available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: I Number of bedroom <br /> i <br /> Character of soil to a depth of 3 feats 24hs.a C r4p"• .,,_... Water table depth <br /> EPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Ll i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Tgal length/size <br /> FILTER BED r {fl!/Distancelto nearest: Well 8 Foundation�_ Pro rty Line S_ r <br /> w o /G U -C rN d d Lo" i. <br /> i <br /> SEEPAGE PITS i I Depth �� Size _ Number <br /> SUMPS El Distance'to nearest: Well Foundation Property Line I <br /> DISPOSAL PONDS ClI <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County J <br /> Horne 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 or sub-contracting signature l <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 compensa- <br /> tion laws of California." -�$ <br /> The applicant must call for all require spections. Complete drawing on reverse side. <br /> Signed ` Title: 1Date: o <br /> Ir F EPART ENT USE ONLY <br /> i <br /> Application Accepted by para � 'p ea 1� <br /> Pit or Grout Inspection by Date Final Inspection b DateA. <br /> Additional Comments: I� <br /> Applicant - Return all copies to Sam Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> II 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE I� AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'No, , <br /> . EH IA-24{REY. <br /> EH;4.2a <br />