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E <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E <br /> ENVIRONMENTAL HEALTH DIVISION AUG 2 f �` �Q <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 I' <br /> ENVIRONMENTAL HEALTH <br /> EXP RES 1 YEAR FR M DATE MUED PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> :s <br /> I Application is hereby made.to San Joaquin County for a permit to construct and/or install the Work herein described. This Ea <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 4 ' <br /> E C• Lot Size/Acreage l <br /> Joh Address ��i <br /> Address v� Phone <br /> Owner's Name • � - <br /> ///1 � i � J License No. Phoneq <br /> Cb raclor Addres <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION o Dut of Service Well _ Cl <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ <br /> Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD• PROP. LINE <br /> _ FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 1:1 Open Bottom` �0 Manteca is. of Well Excavation <br /> a of Well Casing <br /> ° Type of'Casing specifications» <br /> omestic/Private ❑ Gravel Pack C7 Tracy 9 <br /> r n Delta <br /> [:1 Other Depth of Grout Seal Type of Grout l <br /> f'1 Public ! <br /> I I Irrigation _.Approx, WhIstern _Suriace Seal Ii�stalfed y <br /> Repair Work Done ❑ Type of PumH. \\ tate ork Hone <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter j <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted it public sewer is' <br /> available within 200,feet.l <br /> Installation will serve; Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal 1 <br /> • Distance to nearest: Well Foundation Property.Line I <br /> s <br /> LEACHING LINE ❑ . Na. & Length of linesTotal length/size <br /> FILTER BED --C-]-+-Distance to nearest: Well Foundation ' ' Proper V.Line t <br /> SEEPAGE PITS 'hl.,,,,,Depth Size Number .I <br /> } SUMPS LI Distance to nearest: Well Foundation -^--Property Line t <br /> DISPOSAL.PONOS— Cl <br /> I <br /> i I hereby certify that I have prepared this application and that the work will be.done in accordance_wiih San Joaquin county ordinances, state laws, and <br /> ' rules and regulations of the San Joaquin County <br /> l Home owner or licensed agent's signature,cartifies the..tollowing:."I certify-that in-the performance of-the-work for which this permit_is-issued,..) shall not <br /> { ure <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Con tractor's hiring or sub contracting m'pe sa- <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 coen <br /> tion laws of California." <br /> ;Ig <br /> !dp' <br /> p ' t ust c II f r uired inspections. Complete drawing on r rse si <br /> Title: ate: ! <br /> - <br /> ' - O, p R DEPARTMENT USE ONLY <br /> Dat i �- tl Area <br /> Application Accepted by <br /> A` - % Date�z�/-c"IC� <br /> Pit or Grout Inspection by Date Final inspection by <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.. F 0 Box 2009, Stockton, CA 95201 j <br /> i <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> INFO ' " <br /> . EH 13-21(REV.1/9 5) �{ I Q O rtl <br /> EH 14.25 1 1 <br />