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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 3 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95203 <br /> I ' pMIT EXPIRES I Y kR FROM DAIE 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 Se ices. L6�-�L <br /> cY Lot Size/Acreage <br /> Job Address City <br /> r <br /> ssphone' lJ <br /> Owner's Name t <br /> Contractor Address License No f Phone <br /> r <br /> TYPE OF WELL ADO NEW WELL ❑ <br /> TYPE OF WNPELL WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ t *OTHER 13 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .a PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial C] Open Bottom D Manteca ; Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications <br /> I'1 Public [I Other i� F1 Delta Depth of Grout Seal t Type of Grout <br /> I I Irrigation _ Approx. Depth I 1 Eastern ' Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P.' 'State Work Done _ <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material fir Depth '. <br /> Depth I�. Filler Material pth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 0 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence '!' Commercial <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feat: X97 ,�� nn Water table depth <br /> SEPTIC TANK ❑ Type IMfg capacity�l.� No. Compartments r� <br /> PKG. TREATMENT PLT. _ Method of Disposal <br /> ❑ <br /> D)stance�to nearest: Well �_ Foundation._ f O Property LineQ <br /> t ql <br /> LEACHING LINE El No. A Length of linea Total lengthlsixe � <br /> FILTER BED ❑ Distancel.to nearest: _. -Well Foundation��- Property Line <br /> N. ! .Ip ' <br /> SEEPAGE PITS I I Depth d� Site Number h <br /> SUMPS Ll Distance`to neitrest: Well _ Foundation C/6) Property Line <br /> s <br /> DISPOSAL PONDS ❑ IN { <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 /> i rules and regulations of the San Joaquin Countyi <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 /> i employ any person in such manner as to 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 compensa- <br /> tion laws of California." I�. --. .The applicant must call for all re d`inspections. Co plete drawing on revqrse side <br /> Signed I Title: �* . <br /> Date: <br /> F R DEPARTMENT USE ONLY <br /> tication Accepted by ^Vn` Date 1 �r Area �[ <br /> Pit or rout Inspection by To_h"Er Date ~�`am )nal Inspection b d Date" C3 <br /> Additional Comments: <br /> Applicant - Return all copies too: San Joaquin County Public Health <br /> Services, Ehvironmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE AERrJ117 N0. <br /> INFO CASH t <br /> i <br /> . EH 1 -24 IREV.rirr5f <br /> EH 14.20 O`� <br />