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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �a <br /> ENV-IRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON .AVE. , PHONE (209)468-3420 <br /> f <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PER1[IT EXPIRES 1 YEAR FROM DATT_ ISSUED 1 <br /> (Complete in Triplicate) ,", <br /> r ;. Ilk <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the workjherein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. .549 and 1862 and the Rules end Regulations of San <br /> Joaquin County Public Health Services. I <br /> Job Address City ��'� Cot Size/Acreage <br /> Owner's Name _ '�7 � 1_LL dress D hone Y <br /> c <br /> Contractor Address t License No. Phone ! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER ❑ Monitoringiwell �� f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSACFLD. ,PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications! <br /> v Cl Public (a Other f1 Delta Depth of Grout Seal Type of Grout <br /> h,' l <br /> '1,1 Irrigation —.Approx. Depth 1 1 Eastern Surface Seal Installed by f <br /> Repair,Work Done LJ Type of Pump H.P. State Work Done _ i <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth 1 �. f <br /> Depth Filler Material & Depth - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,1 }, REPAIR/ADDITION-1 I DESTRUCTION i I lNo septic syslem permitted if public sewer is <br /> available within 200 feet.l� <br /> installation will serve: Residence_ Commercial_ Other r <br /> Number of living units: Number of bedrooms 3j <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity-' No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal r <br /> Distance to nearest: Well _ Foundation Propert� Line <br /> LEACHING LINE CI No. & Length of lines Taial length/size' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property One 's <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS a 1 <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? <br /> rules and regulations of the San Joaquin County \ ! k­4 <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 sha <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting sign <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 compe� #r <br /> tion laws of California." t <br /> The applicant u t call for all required inspections. Complete drawing on rside. <br /> Signed X Title: Date: / <br /> FOR DEPARTMENT USE ONLY p <br /> Application Accepted by Date��t/� Area L <br /> , 7-- <br /> Pit or Grout Inspection by Date Final Inspection by Date / <br /> Additional Comments: `' �� I",i y (j <br /> Applicant – Return all copies to: Sen.Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IIFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> r EH 13-24(REV.r)x 51 5o.()O �V �` 1 �� 7-I U ( U-8/ <br /> €H <br />