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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)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EKES 1. YEAR FRM DATE lgaUED <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 trade in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _ ��� Ci Lot Size/Acreage <br /> Owner's Name /AIIs3ep� Phone <br /> r _ <br /> Contractor 6& Address License No. t '/�-S Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ <br /> :K PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL—'PITS/SUMPS <br /> 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private - ❑ Gravel Pack ❑ Tracy - Type of Casing Specifications` j <br /> Il Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I IrriUation _Approx. Depth 1 1 Eastern Surface Seal'Installedby f <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material is Depth <br /> I. Depth Filler Material S Depth F ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I i lNo septic system permitted if public sewer is e <br /> F <br /> i v available within 200 feet. <br /> Installation will serve: Residence_ Commercial—1 Other - <br /> Number of living units: Number of bedrooms { <br /> Character of soil to a depth of 3 feet: r �� t { Water table depth i r <br /> SEPTIC TANK ❑ Type/Mfg s rCapacity" No.'Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation ` ProPerty Line <br /> LEACHING LINE ❑ No. & Length of lines / Total length/sizei <br /> FILTER BED n Distance to nearest: Well t�,/Ov -Foundation D-r_-Property Line . ' r — <br /> SEEPAGE PITS t l I Depth Size Numb r <br /> I <br /> SUMPS Ll .Distance to nearest: Well 0 Foundation 62?"' Property Line--427-- <br /> DISPOSAL <br /> _427 DISPOSAL PONDS O "- <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 11 <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 taws 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, f shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican mus or alt re aired ins cti Complete drawing on reverse side. <br /> Signed X Title: Date: ` <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pi r Grout Inspectioniby ate Final Inspection by para r2 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public'Health <br /> Services, Environmental Health-Permit/Services ` <br /> i 1601 E. Hazeltoa.Ave:", P 0 Box 2009, Stockton, CA 95201 <br /> 4 <br />,.�,. INFO AMOUNT DUI: AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'ND. <br /> ,. Eli 13.21 tREV. /N51 <br /> EH 1/-2e o� .�, <br />