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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 4 ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FR M D TF 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 No. 549 and 1862 and the Rules and Regulations of S <br /> Joaquin County Public Health Services. an <br /> Job Address 7 p „ . <br /> •-••- ,-.. .� City Lot Size/Acreage <br /> Owner's Name Address la <br /> .. .,. ... Phone <br /> Contractor Address �l <br /> License No.2-0 = Phone �} <br /> ..+ <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well Cl <br /> + PUMP INSTALLATION EDSYSTEM REPAIR 0 OTHER ED Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation <br /> Ll Domestic I Private 0 Gravel Pack 0 Tracy T Dia. of Well Casing <br /> Type of Casing Specifications <br /> I'1 Public - - - _ I.3 Othear -- C1_Deita—.mowDepth.of Grout Seal..-__._ <br /> t I Irfigalion .. Type of Grout _. <br /> — Approx. Depth I # Eastern Surface Seal Installed by <br /> Repair Work Dane U Type of Pump H.P. <br /> State Work pane_ <br /> Well Destruction ❑ Well Diameter Sealing Materiel & Depth <br /> Depth Filler Material & Depth (, <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION11�71DESTRUCTION I I (No septic system permitted if public sewer is "v <br /> :available within 200 feet.) <br /> Instaliation will serve: Residence-�f Commercial— Other <br /> k . <br /> Number of living units: L Number of edrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. """` — Water table depth ZV <br /> C7�Type/Mfg Capacity No. Compartments ' <br /> PKG. TREATMENT PLT, ❑ r , <br /> :.s-" Method of Di oral <br /> + distance to nearest: WeIE Foundatiori �.fr Property Line iA r I e k <br /> LEACHING LINE Gl'- No. & Length of lines <br /> FILTER BED Total length/size r II <br /> + Distance to nearest: Well Foundation U Property Lined 1 <br /> SEEPAGE PITS r. i Depth Sirer.,.a r <br /> SUMPS MNumber <br /> LI <br /> l Distance to nearest: Well # ' Foundation ` <br /> DISPOSAL PONDS r n_ Property Line <br /> �f� y= <br /> 1 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: "l certity that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner i to become subject toe work <br /> compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the pe+iormance of the work for i <br /> which this permit s issued, E shall employ tion laws of California." p y persons subject to workman's compansa- <br /> The appli t m t tall for all req 'ed i spections. Complete drawing on reverse side 1"r <br /> Signed `� <br /> Title: r <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> - M <br /> d <br /> tion,Accepted'by <br /> Date y I✓ Area <br /> c <br /> t or ro <br /> ut inspetion by Data Final Inspection C� Date <br /> i. <br /> dditional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health I <br /> Services, Environmental Health-Permit/Ser ices <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECVqD BY DATE P <br /> ERMIT'NO. <br /> EH 19.2 IAEY, <br /> EH 14-2e <br />