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I <br /> APPLICATION FOR PERMIT <br /> + SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> I PE MIT EXPIRES 1 YEAR FROMDATE 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 co licence with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1. <br /> F <br /> Job Address City Lot Size/Acreage <br /> i <br /> Owner's Name TVAddress PhoneAnay <br /> Contractor,4 (`-_�!a%1�CJ AddressLicense No. Q ,Phone G <br /> TYPE OF WELL/PUMP; �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C7 SYST,EM REPAIR C] OTHER Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEIPTIC TANK SEWER LINES # DISPOSAL FLD, PROP. LINE <br /> il <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i r <br /> ❑ Industrial C] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> d <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F) Public A Other n Delta Depth of Grout Seal T <br /> YPejof Grout - <br /> I # Irrigation I�Approx. De th 11 EasternSurface Seal Installed by j <br /> r Repair Work Done Type of Pump H.P. J7ll���� _ State WorkI Done <br /> I <br /> Well Destruction ❑ Well,Diameter Sealing Material & Depth <br /> F?e11 W <br /> pth Filler Material & Depth _ _. _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-1 I REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is <br /> ' : available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <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 <br /> PKG. TREATMENT PLT, No. Compartments <br /> C} �I� o ,• '• . , '' w Method of Disposal,' <br />, Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines - `~.Total length/size <br /> FILTER BED ❑ Distance to nearest{ r Well 4 Foundation i y Property Line <br /> h 'IMS 1' 1' ' <br /> SEEPAGE PITS I I De pth Size <br /> --Number <br /> °� <br /> SUMPS LI Distance to nearest: Well• Foundation Property Line t <br /> DISPOSAL PONDS El �� . <br /> I hereby certify that I have prepared this applicatiori'and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and,regulations of the SaPPJoaquin county <br /> Home owner or licensed agent'isignature.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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certifythat in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California.' <br /> P p y persons subject to workman's compensa <br /> The applicant r2usl call r all required inspections. Complete drawing on r e sid . <br /> Signed X ,11. , Title: <br /> Date: D <br /> FOR QVARTMENT USE ONLY ? <br /> Application Accepted by Date yea <br /> Pit or Grout Inspection by II Date-� Final Inspection Date <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 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> GASH <br /> « EM 13.24 IREy.i i n 51 <br /> EH's4•Ta <br /> �N G <br />