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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 �. P <br /> , pgMIT EXPIRES 1 YEAR RO DA2:19 ISSU <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 made in compliance with San Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City 1 -- Lot Size/Acreage <br /> Job Address <br /> t\ <br /> Address <br /> Owner's Name <br /> Phone <br /> - it <br /> License No. Phone " <br /> Contractor Address Well <br /> TY /PUMP:. 1. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of <br /> Servtorice <br /> Well r ❑ i <br /> t_P INSTALLATION ❑ Mo <br /> SYSTEM REPAIR L7 OTHER ❑ <br /> DISTANCE TONE ARES SEPTIC SEWER LINES DISPOSAL FLD. P. <br /> } <br /> FOUNDATION AGRICULTURE WELL OTHER Wf PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION CATIONS <br /> Dia. of Well Casing <br /> n Industrial C]-Open.Bottom--w--�--❑ Manteca - ..Dia. of avation , <br /> Ll Domestic/Private. L1 Gravel Pack ❑ Tracy e of Casing Specifications <br /> Type of Grout f <br /> I'1 Public t #1 Other (1 Delta Depth of Grout Seal -- <br /> I I Ifri6alion Approx. Depth astern Surface Seal Installed by <br /> Repair Work Done U Type of Pu H.P. State Work Done _ <br /> Sealing Material & Depth <br /> Well Destruction ❑ lameter 4 <br /> S` a Depth Filler Material A Depth' <br /> TYPE OF IG WORK: NEW INSTALLATION l I REP.AIRIADDITION I l DESTRUCTION INo septic system permitted it public sewer is ' <br /> T +; ,j ; available within 204 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK- ❑ -Type/Mfg- <br /> PKG. <br /> Capacity_.. - No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal S <br /> a <br /> " Distance to nearest: Well Foundation Property Line t C <br /> LEACHING LINE ❑ No. a Length of lines Total length/size <br /> FILTER BED ❑ 'Distance to nearest: Well Foundation Property Line <br /> SEEPAGE.PITS Il Depth I Size Number s <br /> SUMPS # E l Distance to nearest: Well Foundation Property Line <br /> It <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 /> 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 persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspec 'o s. omelet drawing on reverse sidek/ <br /> IF Date: <br /> \ Y%Signed X_ le' <br /> ( <br /> F07�PAIRITMENT LY <br /> Application Accepted by Date_ �I Area ry <br /> r Date <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return ell copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton. CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH LA I RECEIVED BY DATE PERMIT NO. <br /> INFO At <br /> k EH 13.24(REV.,/RSf r1 ! � 1� 15 <br /> EH 112E �J 1 <br /> I <br />