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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 0 BOX 2009, STOCKTON, CA 95201 <br /> MIRES 1 YEAR FROM DATE ED <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 compliance with San Joaquin County Ordinance Ro. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City 1J. Lot Size/Acreage <br /> Job Address <br /> jfz <br /> Owner's Name �.I� 5 Address Phone L t <br /> ��� r <br /> Contractor' <br /> t h e, Addresses License N041_Phone <br /> TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION Out Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES _ DISPOSAL FLO. PROP. LINE <br /> DISTANCE 70 NEAREST: SEPTIC TANK <br /> f 1 ' FOUNDATION AGRICULTURE WELL OTHER WELL 4 PITSISUMPS <br /> INTENDED TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -- <br /> [a Domestic/Private __- J.❑ Gravel Pack 0 Tracy Type of Casing i pecifications— <br /> l'1 Public1.7 Other <br /> F1 Delta Depth of Grout Seat � - r y of Grout <br /> I <br /> 11 Irrigation ,iK, • Appfox.',Depth i I Eastern Surface Seal Installed by <br /> H.P. State,Work Done <br /> Repair Work Done 'L] �r Type of.Pump x <br /> "" Sealing Material & Depth ++ `- <br /> Weil Destruction ❑ Well Diter <br /> atr�e � � n <br /> y <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> i - <br /> avadi6le Wiiihin 200 feet.I <br /> -� Installaiion will serve:, Residence r 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 ❑ TypaIMfg 1 f Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' Method of Disposal <br /> Distance to nearest:,_Well Foundation Property Lina <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Site Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> a 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 /> fy that in the performance of the work for which this permit is issued, I shall not <br /> Home ownei or licensed agent's signature certifies the following: "I certi <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 mus call mr all re wired inspections. Complete drawing on reverse side. <br /> �� . l <br /> Signed ` � - TiNe: Date: <br /> r <br /> �:!T <br /> 4 <br /> EPARTMENT USE ONLY q f <br /> Application Accepted by , Date [` Area 7/ r <br /> Pit or Grout Inspection by Date Final Inspection by Date r <br /> i <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 /> ' IFEEI NFO CK 9 <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> I 1- <br /> 1 SH 13-2411%EV-irns1 c <br /> EH t{-2a <br />