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APPLICATi6W-Foo PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> t 1601 E. HAZELTON AVE. , PHONE (209)468-3420 J U N 13 191 <br /> P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> ZRMIT EXPIRES 1 YEAR FRAM DATE ISSUED PERMIT/SERVICES <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 / /� r/ / / ► /l?Cl!v�!` r r 1..:,_. 1� Ci Lot Size/Acreage <br /> ner's Na Phone <br /> / r <br /> i + No. hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP11ACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD. - H 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 /> Dgmestic/Private ❑ Gravel Pack ❑ Tracy :Type of Casing Specifications <br /> F <br /> I'I Public f_1 Other. F1 Delta Depth of Grout Seal Type of Grout <br /> l I Irrigation _..Approx. Dep I Ea fern � Surface Seal Installed by <br /> t <br /> Repair Work Done U Type of Pum _. H.p�4 State Work Don <br /> —Seals Material b Depth <br /> F <br /> Well Destruction ❑ Well Diameter � ng eP <br /> Depth Filler Material & Depth , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION 1 I .INo septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence Commercial— Oilier <br /> Number of living units: Number•of"bedrooms ; <br /> Character of soil to a depth of 3 teelr----`—^"^"' Water table depth <br /> SEPTIC TANK. ❑ TypelMfg - Capacity No: Compartments <br /> PKG. TREATMENT PLT. G7 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ . No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance'to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I I Depth t Size _ Number i <br /> SUMPS l l 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 /> rulr3d re5latit57iof'ttie Sn'Joaqu�iri Court"ty=' "*""' --`, — "° = _� —.. <br /> Home owner or licensed agent's signature certifies the following: 1}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 14 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 appllca t st c I for I equired insp ctions. Complete drawing on arse si <br /> Sig d TiU Date: <br /> FOR KPARTMENT USE ONL <br /> rl 61 <br /> Application Accepted by r Date Area O <br /> Pit or Grout Inspection by Date Final Inspection bv � � Data Z6 -� [ <br /> Additional Comments: <br /> i <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 21)09, Stockton, CA 95201 <br /> FEEI <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13-24(REV,tins) �/J,'/J� Cf A <br /> gnl <br /> EH 14.28 <br />