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f <br /> APPLICATION FOR PERMIT <br /> r SAN JOAQUIN COUNTY PUBLIC HEALTd SERVICES <br /> ` ENVIRONMENTAL HEALTH DIVISION <br /> I 1601 E. HAZESLTON AVE. , PHONE (209)468-3420 <br /> { P O BOX 2009, STOCKTON, CA 95201 <br /> PEIMIT EXPIRES 1 YEAR FR Y DATsE 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City hot Size/Acreage <br /> Address �'a'�9" Phone l� <br /> 'I . Owner's Name f <br /> Contractor Address �^ License NO..T `� Phone <br /> f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER C3 Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> k FOUNDATION AGRICULTURE WELL OTHER WELL PIT SUMPS _ <br /> I INTENDED USE TYPE OF WELL Pfi06LEM AREA'"'-CONSTRl1CTION-SPECIFICA <br /> 171 Industrial ❑ Open Bottom ❑ Manteca ^ Dia. of Well n r Dia. of Well Casing <br /> 1-1 Domestic/Private ❑ Grave! Pack ❑.Tracy 1 o Casing Specifications <br /> I"! Public [.1 Other a Depth of Grout Seal 1 Type of Grout �(\ <br /> I I Irrigation Approx. epth l I Eastern Surface,Sdul Installed by U� <br /> Repair Work Done ❑ Type of Pump HSP;m State Work Hone T <br /> Well Destruction O Well Diameter i - Sealing lrfaterial,8 Depth f r <br /> I Filler Mtial <br /> a <br /> r er "to l/\ <br /> Depth _ _— - r <br /> F TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/AD`DITIONDESTRUCTION i I (No septic system permitted if public sewer is <br /> j w..,,t,_ available within 200 feet.l <br /> Installation wit] serve: Residence Commercial_ Other' ' <br /> Number oftiving units: 1— Number of bedrooms .2 <br /> Character of�soil.to a depth of 3 feet: t - -- _Water table depth <br /> SEPTIC TANK. 0 Type/Mfg �'l }.► Capacity No. Compartments <br /> V.q <br /> PK_ TREATMENPI]T. ❑ P i Method of Disposal <br /> Distance to nearest: Well p Foundation E0Q Property Line _Aa <br /> op <br /> LEACHING <br /> LEACHING LINE X No. & Length of lines ' � Total length/sire of <br /> FILTER BED 0--Disfance to'nearest: �1Nejl Foundation Property Line <br /> SEEPAGE PITS X Depth �S� 5iie� .�" Number 1 _� <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> F DISPOSAL PONDS ❑ 1 1 <br /> I hereby certify that I have prepared this appilcation 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 I <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 rttanner as to b6come subject to workmen'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•shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m call for all required in pecti s. Complete drawing on reverse side. <br /> Signed X Title:' Date: / <br /> f RTMENT USE ONLY j <br /> Application Accepted by Date — i Area <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE t <br /> f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> r 7. EH 13-24(REV.1 i n a <br /> EH A ` <br />