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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 � [� <br /> f P 0 BOX 2009, STOCETON, CA 95201 <br /> I. REMIT EXPIRES 1 YEAR FROM DATE .ISSUED <br /> (Complete in Triplicate) <br /> p p e) <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 ` / v • City Lot Size/Acreage <br /> � 1 <br /> -- <br /> Owner's Name _'' �fatQ2.� ,� -__ Address Z3e)� Phone <br /> Contractor Address Z P // <br /> License No,`. Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT 0 DESTRUCTION ❑ but of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER El Monitoring Well C7 i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO !CATIONS ~ <br /> n Industrial v 1 D Open Bottom ❑ Manteca Dia. Excavation Dia. of Well Casing <br /> EI Domestic/Private-O"' 0 Gravel Pack ❑ TracN ype of Casing��.t. y 9 Specifications. <br /> f'l Public ' [-1 Other fl D Depth of Grout Seal Type of Grout n <br /> t <br /> I I Irrigation w�.Approx. Depth Eastern Surface Seul Installed by j <br /> Repair Work pone 0 Type of Pump '.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material& Depth <br /> Depth - Filler-Material & Depth -_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION 1 1 DESTRUCTION INo 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: i <br /> Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments _ <br /> PKG. TREATMENT PLT. ❑ l <br /> Method of Disposal <br /> r <br /> Distance to nearest: g Well Foundation Property Line h <br /> LEACHING LINE 0 No. & Length of lines fi Total length/size <br /> FILTER BED E) Distance to nearest: Well Foundation _ Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS q <br /> I hereby certify that I have prepared this application and lth5i"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 /> 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 applicant ust call for all rpqui ed.' spec <br /> ti s ,Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date 1 Area <br /> Pit or Grout Inspection by Date Final Inspection by Data �1 <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 AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'N0. <br /> + EH t7-24!REV,r/HSI t7 M.-tJ `�1��- � a 1 <br /> EH 14.2e MQ <br /> C U kp <br /> 1 <br />