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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 /> P O BOX 2009, STOCKTON, CA 95201RMIT pp ,' <br /> EXP RES 1 YEAR FROM DATE ISSUM IVB l <br /> (Complete iia 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 .,��� g �' IGG City $7KAJ Lot Size/Acreage <br /> Owner's Name `D " dgiLAddress <br /> Sl1-Y•-• Phone 5'2_4 <br /> Contractor /= 'Lc9oo�- —Address License No._! 4 -7 Phone GS'3`37 <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM-REPAIR=:`]�" OTHER ❑ <br /> Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SE ER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AG ICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A EA CON UCTION SPECIFICATIONS <br /> f� Industrial ❑ Open Bottom ❑ Manteca of Wall Excavation Dia. of Well Casing <br /> T e of Casing Specifications it <br /> C:l Domestic!Private 111 Gravel Pack ❑ Tracy YP 9 <br /> i-1 Public Ci Other n Delta epth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Easter 5 ace Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Maters ., & Depth t J\ <br /> Depot Filler Material J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I DESTRUCTION iNo septic system permitted if public sewer is <br /> ,// a liable 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` __ ¢a' Capacity _ No. Compartments <br /> PKG, TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No..& Length of lines I Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS ❑ 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 /> r Home owner or licensed agent's signature certifies the following: "I call 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." l <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Vf <br /> Application Accepted by Date Area <br /> ' Pit or Grout Inspection by Data Final Inspection byA Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> r Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P x 2009, Stockton, CA 95201 <br /> FEE AMOUNT,DUE. ....-.—AMOUNT,REMITTEDy . .- CASH' Y=,.__.RECEIVED BY ... t- :-DATE - PERMIT'NO. <br /> INFO <br /> . EN1}2ltrlev.+iNsl 3 A& <br /> FHA-25 <br />