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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> pERMIT MIRES 1 YEAR FR M DATTti ID <br /> (Complete is 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 San <br /> Joaquin County Public Health Services. <br /> Lot Size/Acreage <br /> Job AddressCity: � ---p-4k <br /> ""`+ <br /> Owner's Name Address <br /> 5 T� Phone <br /> r `]Cf' <br />' r � ddress +� License No.�Phon �.] <br /> Contractor Well .� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well LI <br /> PUMP INSTALLATION O SYSTEM REPAIR_❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN£S -rte DISPOSAL`FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r <br /> C} industrial C] Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1, Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"1 Public (-I Other n Delta Depth of Grout Seal Type of Grout <br /> + I I Irrigation _..Approx. Depth I I Eastern Surface-Seui_Instalfed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ Y` <br /> Well Destruction ❑ Well DiameterSealing Material & Depth <br /> Depth f:. Filler Material&Depth Y. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION ( I DESTRUCTION iNo septic system permitted if public sewer is <br /> E vailable within 200 feet.1 <br /> Installation will serve: Residence= Commercial _ Other <br /> Number of living units: „ Number of bedrooms <br /> t <br /> Character of soil to a depth.ot 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �+Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> �- LEACHING LINE ❑ 'No. & Length of lines Total length/size <br /> FILTER BED l=1 iDistance to nearest: Well Foundation Property Line ` <br /> I <br /> ! SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> 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 /> Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California.” Contractor's hiring or sub-contracting signature <br /> certifies the followin certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> 1 tion laws of Catifor,Ia." <br /> { The applicant must a1i i a r quired inspections. Complete drawing on revere de. <br /> f Pate: �� � <br /> Signed Title: - — <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by _ �.�i 4 4, .S <br /> Data <br /> 7 3 ✓ Area <br /> Pit or Grout Inspection by Date Final Inspection by S/�._�,/ Date <br /> Additional Comments: 1 / v <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> I Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> t.//- eEH 53 24 IAEY.1i K 51 c 0� 7 / (0-vK'A <br /> EH 14.21! [ <br />