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APPLICATION FOR PERMIT j <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 11601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> ' P O BOX 2009, STOCKTON, CA 95201 <br /> 1: I <br /> -PY"IT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made tq 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'Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> e-VJob Address City of Size/Acreage <br /> f r� 4 j <br /> Owner's Nam P <br /> N Address �. � � hone <br /> KContraclor Address License No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well I <br /> PUMP INS kALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �� ��qp <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6( <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1'.) Domestic/Private ❑ Gravel Pack L] Tracy Type of Casing Specifications <br /> !'I Public C7 Other 1 f-1 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _.Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Materiel 6 Depth <br /> Depth I Filler Material & Depth r <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION i I {No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence II' Commercial— Other <br /> Number of living units: Numlber of bedrooms _ <br /> Character of soil to a depth of 3 feet,I: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ q _ ., <br /> . . Method of Disposal ( . <br /> Distance to nearest: Well l Foundation Property Line <br /> II <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance ao nearest: Well Foundation Property Line <br /> �j <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS ❑ ;I i <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 i <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 applican II for all re ' ins ions. Complete drawing o averse side. <br /> Signed X title: cz�'�-..- Date: <br /> � I � <br /> :� F R DEPARTMENT USE ONLY <br /> Application epted by Date l5` Arsa�_�� <br /> Pit or Grout Inspection by I� Date Final Inspection by <br /> r / <br /> Additional Comments: <br /> r110 Jj=— <br /> Applicant - Return all copies to,l` San Joaquin County public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> INFO MOUNT DUE I� AMOUNT REMITTED CASH RECEIVED BY DATE_ PERMIT'NO. <br /> EH 3-24 i EH 11•�E(REV.r/n sl I 3S <br /> I� <br />