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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HE LTH NE DIVISION <br /> 1601 E. HAZTLTON AVE. , CA 95201 <br /> P O BOX 2000, STOCKTON, , <br /> p RES 1 YEAR FR M DAT <br /> (Complete in Triplicate) <br /> made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> Application is hereby lienee with Sen oun'Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> application is made in comp <br /> Joaquin County public Health Services. Tp,f✓ Lot Size/Acreage <br /> �t L City <br /> Job Address ) Phone 3 <br /> F 14, / ev Address <br /> Owner's Name j <br /> O� <br /> License No. Phone <br /> �L� Address DESTRUCTION ❑ Out of Service Well Cl <br /> Conlractor WELL REPLACEMENT ❑ Monitoring Well C7 <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR © pROp LINE <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. ` <br /> SEWER LINES __�- PITS/SUMPS <br /> i DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL i <br /> FOUNDATION'{�---- <br /> INTENDED-USE TYPE OF WELL ,.PROBE_ EM AREA CONSTRUCTION SPECIFICATIONS r Dia of Well Casing <br /> ❑ Open Botiam P Manteca Dia, of Well Excavation "` Specifications <br /> �hninduslrial0 Tracy Type of CasingDomesticlPrivat. Cl Gravel Pack Type of GroutI1 Public NI-1 Other n Delta <br /> Depth of Grout Seal <br /> Surface Seal Installed by <br /> L `� Approx. Depth I I Eastern State Work pone <br /> I I Irrigation s - <br /> Repair Work Done L7:,�Type of Pump — -- -- sealing Material 5 Depth <br /> Well Destruction ❑:, Well Diameter _ -- — <br /> Filler Material 5 Depth <br /> Depth <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INS <br /> installation <br /> T ,i REPAIRIADDITION l I DESTRUC7lON (No septic system permitted if pub+c sawar + <br /> Installation will serve: Residence.-9- <br /> Commercial Other -L - <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a.depth of 3 feet: Capacity ----- No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg Method of Disposal <br /> i <br /> f PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> F- Distance to nearest: Well r <br /> Total length/size <br /> LEACHING LINE 0 No. & Length of lines Property Line <br /> FILTER BED [:] Distance to nearest: well <br /> Foundation <br /> P <br /> I - Sire Number <br /> SEEPAGE PITS Il Depth Property Line <br /> c SUMPS ``} C1 Distance to neatest: WellFoundation .�-- <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, an r <br /> rules and r&gulaiions 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 signature <br /> she not/ <br /> employ ahy•person in such manner s o become <br /> subject <br /> u je ce of oworkman'sthe work for which compthis permitation vis issued,s of fAshall employ perosonslsubject to workmaring or n's sub-contracting <br /> certifies the following: "I can y pe <br /> tion laws of-California." / <br /> The applicant must call for all required inspections. Complete drawing on reverse side. y�� t <br /> /s• Title: Date: -- <br /> Signed X <br /> i FO NT USE ONLY 4 <br /> I Date Area i <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date_ Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Sari County Pub <br /> ServJoaquin,' Evi onmentaliHealthtPermit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> C CK <br /> FEE s AMOUNT DUE AMOUNT REMITTED H RECEIVED BY GATE PERMIT NO. <br /> INFO <br /> . EH13-24(REV.I/x51 3s•� , �S '�-� �� ��-�3°. <br /> EH 14.26 <br /> t <br />