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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 0 BOX 2009, STOCKTON, CA 95201 <br /> MERMIT EXPIRES 1„ YEAR FROM DATE ISSUED <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ) y� <br /> Job Address / / J ��� City AAAYD Lot Size/Acreage P <br /> Owner's Name 3n Y Y A), / f 4f'IDY Address . _l 774-0 S2X •�/L7 t-P_ Phone <br /> I <br /> Contractor Z� ,N l�_ Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTIONX Out of Service Well ❑ <br /> 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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_-i Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing Specifications <br /> I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grou o a <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by j <br /> Repair Work Done 0 Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth � <br /> `r <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DEST UCTION I I {No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Othe <br /> Number of living units: Number of bedrooms j <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg - AFoun <br /> city No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest:. Wetl n Property Line <br /> LEACHING LINE ❑ No. & Length of lines - <br /> Total length/size <br /> FILTER BED L-1Distanceto nearest: Well Foundation Property Line V <br /> k r <br /> SEEPAGE PITS 11 Depth Siz <br /> SUMPS Ll Distance to nearest: ail Foundation Property Line I <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that f 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 persons subject to workman's compensa- <br /> tion laws of California." L <br /> The applicant must call for all required 1 spections. Complete drawing on reverse side, !r ! <br /> Signed X Title: Date: <br /> t FOR EPARTMENT USE ONLY r '' <br /> Applice4ion Accepted by �� Date Area <br /> Pit or Grout Inspection by Date Final Inspection � Date <br /> T� <br /> Additional Comments: 7D <br /> Applicant - Return all copies to: San Joaquin County Public Health 0 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> EH A-24 fREV,1 N51 �` V +O~{ � <br /> fH:�-26 5 <br />