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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, STOCETON, CA 95201 <br /> pgNIT EXPIRES 1 YEAR FROM I TE 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 /> applicatiotr is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Puublic.Health Services. '� ,P <br /> 7 1�"+ + <br /> City �fl�� Lot Size/Acreage F <br /> Job Address <br /> ` La.4- �5� y Phone � 7 ! <br /> —i�ddress <br /> Owner's Name <br /> Contract (A Address r 1 -� � L_�License No. 2 Phone <br /> or ' '� <br /> TYPE OF WELL/PUMP: NEW WELL`JiL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> Monitoring well L1 <br /> PUMP INSTALLATION D r SYSTEMREPAIR0 OT�iER C1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 15'41 s___ DISPOSAL FLD. Z) PROP. UNE <br /> FOUNDATION AGRICULTURE WELL en OTHER WELL�� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E-1Industrial PICTen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �omestic/Private _ Cl.GraveLP_ack...�- --Lq Tracy- Type of-Casg inT Specifications <br /> - <br /> ('I Public Cl Other n Delta Depth of Grout Sealtr`f� r pe of Grout <br /> I { IrrrOation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done- [7 Type of Pump H.P. State Work Done U <br /> Well Destruction ❑ Well DSealing plater th <br /> iameter <br /> Depth Filler-Material &'Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1 1 DESTRUCTION l I (No 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 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: W Foundation Property Line <br /> LEACHING LINE ❑ No. & Length o nes Tota! length/size <br /> FILTER BED LI Distance nearest: Well Foundation Property Line <br /> SEEPAGE PITS �Iplh Size Number <br /> SUMPS ce 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 /> 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 persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must cal �An7clions. a rowing on reverse side. <br /> Signed X <br /> r= <br /> Titla: Date: ��� <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date ? [ Area <br /> Pit Gr ut I apection by Date Final Inspection by Date <br /> Additional Comments: AA O C - <br /> Applicant -- Return all copies to: Sen 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 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . <br /> SH I:v.+,K N %n.oU <br /> ( E H 1 20 <br />