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APPLICATION FOR PERMIT r}tip i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIX EXPIRES 1 YEAR FROM DATE ISSUED <br /> r ? <br /> r (Complete in Triplicate) r <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: n Joaquin Coouuntty�-Ordinance o. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 9 �.O'� Affu#�' <br /> Job Address / Q� City Lot Size/Acreage <br /> Owner's Name &w4 � Address Phone <br /> Contractor ) �`�;�,% Address License'No��0 Phone�r —1 __ I <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT F7 DESTRUCTION ❑ Out of Servr�iccee Well ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER <br /> . 1 °C +° Y;ll s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE GWY <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,, p <br /> E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Pt <br /> ma. Of weaft ex0mv <br /> n Industrial ❑ Open Bottom C1Manteca Dia- of Well Excavation <br /> F'l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> I'I Public (-I Other n Delta Depth of Grout Seal o <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seat Installed by <br /> _ <br /> r Repair Work Done 0Type of Pump <br /> H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material 5 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> l Installation will serve: Residence-,.^.. Commercial— Other <br /> t <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/Mfg Capacity No. Compartments {� <br /> PKG. TREATMENT PLT. ❑ Method of Disposal LJ" <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines Total length/size <br /> FILTER BED 1=1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> 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." <br /> The epplican u� I far ! red inspections. Complete drawing o verse side., _ <br /> Date: zS <br /> I <br /> Signed X Title: ---- <br /> FOR EP RTME T USE ONLY l� <br /> Application Accepted by Date -Area �( <br /> 72V <br /> Pit or Grout Inspection by Hate Final Inspection by to <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 AMOUNT DUE AMOUIIT REMITTED CK i CASH RECEIVED BY DATE PERMIT•NO. <br /> INFO f} <br /> a EH 3-24(REV.Find C096 <br /> EH 14.26 VV <br />