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APPLICATIM FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468_3420 MACIHADO, 11yC. <br /> P O BOX 2009, STOCKTON, CA 95201 247 N,Jacktone Road <br /> YEAR FROM ED Stockton,0011fomill 96215 <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 No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> Job Address e <br /> IRL <br /> Q City e) 8Q fLat Size/Acreage Q <br /> Owner's Name }© .� ` Address Phone <br /> Contractor 4 �"'• �- <br /> Addres c �WQ License No f'fran 2 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ jt� WELL`REPLACEMENT ❑ <br /> DESTRUCTION LI of Service Well ❑ <br /> PUMP INSTALLATION ❑ i ' 'SYSTEM REPAIR'®.` <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER C Monitoring Well <br /> -- SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ,,,— OTHER WELL <br /> ' PITS/SUMPS <br /> INTENDED USE <br /> TYPE OF WELL PROBLEM AAEA CONSTRUCTION SPECIFICATIONS <br /> C� industrial ❑ Open Bottom O Manteca' i Dia. of Well Excavation <br /> fa Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> F• Public f:7 OtherF) Delta Depth of Grout Seal "\--� <br /> Specifications <br /> �lrrigation —Approx. Det t I Eastern Type of Grout <br /> (�{� <br /> Surface Seai Installeid by <br /> Repair Work Done V Type of Pump ?� H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth State Work Oona <br /> Depth Filler Material & Depths` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDfTION,( I DESTRUCTION I f INo septic system Permitted if public sewer <br /> Installation wil! serve; Residence available within 200 feet.-) <br /> Commercial,•„ Othar � <br /> "'Number ofiliving units:"' . 'Number of bedrooms � t' <br /> Ch'aracter}of soil to a depth of 3 feet: w <br /> SEPTIC TANK., ❑ Type/Mfg Watertabfe depth <br /> PKG. TREATMENT PLT. ❑ Capacity a No. Compartments , <br /> x _ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation :*:-7A7 -' ` <br /> 4 . <br /> Property Line�" rC { <br /> LEACHING LINEr <br /> ❑ No. 8 Length of lines �- <br /> FILTER BED Total length/size <br /> (1 Distance to nearest: Well Foundation <br /> Property Line v <br /> SEEPAGE PITS 11 Depth Size <br /> SUMPS — Number <br /> LI Distance to nearest; Well Foundation <br /> DISPOSAL PONDS ❑ � Property Line � <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin courity 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of Califormance rnia.-Contractor's <br /> work for rhiringch r or sub-contracting s permit is issued, l signnot <br /> ature <br /> certifies the following: "I certify that in the performance of the work for which this Permit is issued, I shall em to <br /> tion law&of California." p P y persons subject to workman's compensa- <br /> The applica for all required ' spectio . Co lata drawing ontz arse side. <br /> Title: <br /> Signed f Date. <br /> : <br /> �F�OEP�AIRT*E�NTUSIE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Data ___�� <br /> Final Inspection by � � Dat <br /> Additional Comments: <br /> ".P <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'NO. <br /> Ek 13.24 1REV.$I"a) ' <br />