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i <br /> APPLICATION FOR PERMIT Z% <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> r11 EXP RES 1 YEAR FROM kTB ME <br />} (Complete in Triplicate) <br /> t to construct and/or install the ;rork <br /> Application is hereby made to San Joaquin County for a permi ,_,herein described.;. This <br /> in County Ordinance No. 549 and 1862 and the .1uaes and Regulations of San <br /> application is made in Compliance with San Joaqu <br /> Joaquin County Public/#Tlth Services. <br /> City % Lot Size/Acreage <br /> Job Address <br /> C/ - - Address Phone <br /> Owner's Name _.,. <br /> Contractor° Add <br /> License No. Phone <br /> ress <br /> r WELL.REPLACEME,NT n DESTRUCTION_0 Out 6f Service Well ❑ <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ �.rt __� - ��� +�-r �_ .,.Monitoring Well E7 <br /> k �i T SYSTEM REPAIR ❑ OTHER ❑ <br /> 1 PUMP INSTALLATION C] E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL-"' " OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Q Industrial ❑ Open Bottom C3 Manteca Dia. of Weil Excavation Specifications <br /> { C1 Domestic/Private ❑ Gravel Pack D Tracy Type of.Casing <br /> iI:1 Other n Delta -Depth of Grout Seal Type of Grout <br /> Public kP <br /> I I Inioation ._.,,Approx. Depth 1 I Eastern Surface Seal installed by <br /> Repair Work Done LJ 1,{-Type of Pump H,P, State Work Done J <br /> Sealing Material &,Depth l <br /> Wel! Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIR/ADDITION"1 RUCTION I I lNoavasepticlable system <br /> ithin m rented if public sower is <br /> Installation will serve:- Residence Commercial ` Other <br /> Number of living units: L Number of be ms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> ' -=- <br /> PKC. TREATMENT PLT. Method of Disposal <br /> [3 ..�-....�.--.�--�... <br /> Distance to nearest: Well Foundation .Property Line <br /> i 4 <br /> LEACHING LINE �Ie�B Length of lines � p ppTotal !@ngthlsize <br /> FILTER BED ❑ Distance to nearest: Well—( FoundationcLl( Property Line <br /> r <br /> SEEPAGE PITS I�--Bt''pth Size NuMber <br /> r Line i SUMPS 1 LI Distance to nearest: Well' Foundations Property ) <br /> r 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 /> 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 <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 Celifor a." <br /> e applica st all or all r ons. C late wing on rev$rse side, ` <br /> Sign <br /> ills: d Date: <br /> OR DEPARTMENT USEONLY . ' <br /> Area <br /> ' V _ <br /> Application Accepted by f " Date <br /> Pit or Grout Inspection by Date Final.inspection by AAWA Date } <br /> Additional Comments: <br /> 1 <br /> ` Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services n`1' <br /> 1601 E. Hazelton Ave., P 0 Boz 2009, Stockton„CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'N0. <br /> �] <br /> FEE <br /> I <01 <br /> . EH 13.2 (REV,iinoi s� 4}'(3� �. 1L ..�� <br /> EH 14-26 11t - <br />