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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIROM&ENTAL HEALTH DIVISION ' <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> ' P 0 BOX 2009, STOCKTON, CA 95201 <br /> RLS 1 YEAR R M DATE LOWER <br /> (Complete in Triplicate) <br /> e to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> Application is hereby mad <br /> application is made in comitance with San Joaquin county ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. cc <br /> ��� L JP1:5 City S 0(f-kT°A1 Lot Size/Acreage ° <br /> Job Address <br /> ��'r�. Address �— Phone J , <br /> Owner's Name <br /> S�Et��,�U License No. Slo2oi-�S phone"Wel�l <br /> Contractor Ad6ressTYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of OTHER MonPUMP INSTALLATION ❑ SYSTEMMRREPAIR ❑ - 1 <br /> SEWER LINES � � DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK LIMPS <br /> I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/Sr <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing � Specifications <br /> C7 Domestic/Private f�-Gravel Pack ❑ Tracy © ' Type of Grout � � <br /> ('1 Public <br /> (:1 Other n Delta Depth of Grout Seal <br /> 11 Irrigation 9�,Approx. Depth I I Eastern Surface Seal Installed by <br /> H P State Work bona _ <br /> k Repair Work Done U Type of Pump sling Material & Depth ,�State <br /> Work <br /> y' <br /> Well Destruction ❑ Well Diameter <br /> i r _ Filler Material b Depth <br /> Depth to <br />'r. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAiRlADDITION I I DESTRUCTION I 1 availa avac system ilable within 200 fest'tied it public sewer is <br />�I Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ f <br /> Distance to nearest: Well Foundation Property Line <br /> Total lengthlsize <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS Il Depth Size Number <br /> SUMPS L1 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 /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which his permit is issued, I she not <br /> ecome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to b <br /> work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> certifies the following: "1 certify that in the performance of the <br /> - <br /> tion laws of California." <br /> The applica m for all require ins .tions. Complete drawing on reverse side. <br /> Signed <br /> Title: Date' <br /> FOR DEPARTMENT USE ONLY <br /> e � tr <br /> Date Area <br /> Application Accepted by Z �/ <br /> V 2 <br /> l Pit or Grout Inspection b <br /> Date G Final Inspection by Date �' <br /> Additional Comments: <br /> Applicant - Return all 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 /> A CK CE ED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTEt7 CASH <br /> �AJ POO <br /> 00 <br /> EH 13-7f 1REV,11n 5f .�. <br /> y EH Sf•2a <br />