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a <br /> APPLICATION FOR PERMIT <br /> SAN 30ARUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EKPIRES 1 YEAR FROM DA' E <br /> ID <br /> (Complete in Triplicate) <br /> made to San Joaquin County for a permit to construct and/or instal� l the work-herein described. ThiServe <br /> Application is <br /> he lienee with San Joaquin Count Qrdinanee Ho. 549 and 1862 and the Rules and Regula <br /> application is made in comp <br /> Y <br /> Joaquin County Public Health Services. Lot Size/Acreage <br /> Cit <br /> Job Address Phone <br /> �� Address <br /> Owner's Name 4e <br /> Address . <br /> R iw S? • GS 1) `<� License No. ;13�8 Phone <br /> Contractor WELL REPLACEMENT LJDESTRUCTION ❑ Out M Serviceonitoring Well <br /> NEW WELL C1 OTHER ©' Monitoring <br /> TYPE Of WELLIPUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION El DISPOSAL FLD. PROP. LINE <br /> • FEWER LINES .�.---� PITS/SUMPS <br /> FOUNDATION <br /> DISTANCE TO NEAREST: SEPTIC TANK �---- AGRICULTURE WELL OTHER WELL— <br /> �— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing <br /> Dia. of Well Excavation <br /> ❑ Open Bottom [3 Manteca Specifications <br /> Cl Industrial �'— <br /> ❑ Tracy Type of Casing s-p�e 04,t <br /> {l Domestic/Private ❑ Gravel Pack Type of Grout <br /> I:} Other n Delta Depth of Grout Seal <br /> 11 Public Surface Seal Installed by <br /> I I tfrigation Approx. Depth I I Eastern State Work Done <br /> Type of Pump ,_ __---- <br /> H.P, <br /> Repair Work Done U YP Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> Filler Material d, Depth <br /> r �S'6/t ci/�he P<;w fr Depth <br /> TYPE Of SEPTIII C WORK: NEW INSTALLATION l I REPAIRlADD1TION l I DESTRUCTION I i available within 200 feet11);Ifp,,blc <br /> ifisower is <br /> Installation will serve: Residence— Commercial — Other�-- v <br /> t <br /> Number of living units: Number of bedrooms�____�- Water table depth <br /> Character of soil to a depth of 3 feet: Capacity��--- No, Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well <br /> 4 <br /> t Total length/size <br /> i LEACHING LINE CI No. & Length of lines Property Line <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation ��— <br /> SiNumber <br /> SEEPAGE PITS 11 Depth ze property Line <br /> SUMPS <br /> Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that cordance with San Joaquin county ordinances, state laws, an <br /> I have prepared this application and that the work will be done in ac <br /> for <br /> rules and regulations of the San Joaquin County following: <br /> Ili Home owrner or liced, I shall not <br /> ^�such mannergas w bome sub ectt to workman's <br /> rtcompensai on laws of performance <br /> ," Contractor'swhich <br /> lhui gr or sub-contracting s permit is asignature <br /> I <br /> any pe <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicat must call for all required inspections. Complete drawing on reverse side. <br /> Date: J <br /> Title: <br /> Signed <br /> �PJt FOR DEPARTMENT USE ONLY <br /> l Date Area <br /> 4i Application Accepted by '�°�� <br /> l � Final Inspection by Date <br /> Pit or Grout Inspection by Date -- <br /> Additional Comments: <br /> San Joaquin County Public <br /> Applicant - Return all copies to: ic Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 - <br /> CK El ED Y DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH 13-24 IREV. <br /> 4 cu 1.95 <br />