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APPLICATION FOR PERMIT �!''•C ` <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONN[ENTAL HEALTH DIVISION I 68-'3420 <br /> 1601 E. HAZELTON AVE. , y <br /> P O BOX 2009, STOCKTON, CA 95201 rVO ] <br /> ggp RES 1 YEAR FR <br /> (Complete in Triplicate) <br /> work <br /> in <br /> Application is hereby made to San withuSanCJOagUin�county r a rordinance mit to nNo. 549struct 8and o1862s�dltheeRules and Regulations dof Sans <br /> application is made in compliance with <br /> uin county Public Health Services. Lot Size/Acreage <br /> City G'�"r7� ��— <br /> Job Address 6150 <br /> Phone <br /> d Address !$ <br /> Owner's blame <br /> License No.-,—�—Phone <br /> s0 t Address y 5' Drat of Service Well ❑ <br /> Contractor WELL REPLACEMENT C� DESTRUCTION ❑ <br /> NEW WELL ❑ OTHER ❑ Monitoring Well ci <br /> T PE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD, PROP. LINE <br /> SEWER LINES �----- PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL _ OTHER WELL�- <br /> FOUNDATION �---- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR-UCT-ION-SPECI -C—ATk�N�p a of Well Casing <br /> 0 Open Bottom O Mantaca�ia. of Well Excavation <br /> P Industrial Specifications <br /> racy Type of Casing Type of Grout <br /> C7 DomesticlPtivate ❑ Gravel Pack Cl Delta Depth of Grout Seal <br /> ['i Public I1 Other <br /> �.Approx. Depth ! I Eastern Surface Seal installed by <br /> i I Irrigation H P State Woik-Dane_ <br /> Repair Work Do Type of Pump Sealing Material & Depth <br /> fff <br /> Weil De ction ❑ Well Diameter ---- Filler Material & Depth <br /> Depth <br /> available within 200 feet. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 14 REPAIRlADDITION I I DESTRUCTION I ! lNo septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial Other <br /> i 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 0 Type/Mig Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation��--- Property Line <br /> I Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE Cl No. $ Length of lines Foundation Properly Line <br /> FILTER BED C1 Distance to nearest: Well <br /> + Size Number <br /> SEEPAGE PITS 11 Depth Foundation - Property Line <br /> SUMPS L'! Distance to nearest: Well <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, ander <br /> rules and regulations of the San Joaquin County hat in the rformance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "l certify t Pe signature <br /> aR i esefto person in such <br /> "I certify enay that n the performance of he work fot to rwh ch this permit is issued,ation laws of fI shall employ persons ornia." Contractor's lsubj ct to workman�scompensa- <br /> c g: <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> i Date: <br /> I <br /> Signed X Title: <br /> FO PARTMENT USE ONLY <br /> Fea <br /> Date A r <br /> Application Accepted by <br /> Date , <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> � Additional Comments: <br /> Applicant ^ Return 911 copies to: San Joaquin ftY1ronmennty tal HHealthtPermit/Services <br /> F 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CKRECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH 13.24(REV.r/R Sl l <br /> #H—26 <br />