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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION u <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 �� <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> ' RMUIT 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 an <br /> Joaquin County Public Health Services. d Regulations of San <br /> C Job Address ff �� Y1] +: City Lot Size/Acreage <br /> f Owner's Name /r D f�'il�D^` Address Phone �� <br /> Contractor Aje _i14 - Address ® QyL <br />° License No. Phone 7 <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WEL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANKL7 <br /> 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 /> n Industrial , <br /> C1 Open Bottom 13 Manteca Dia. of Well Excavation <br /> C7 Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> E] Tracy Type of Casing Specifications <br /> I'I Public [a Other I� Delta ` <br /> r Depth of Grout Seal Type of Grout <br /> I # Irrigation �..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.p <br /> Wel! Destruction - State Work bane_ <br /> ❑ Well Diameter r Sealing Material & Depth <br /> Depth { Filler Material. b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted it public sewer is <br /> Installation will serve: Residence Commercial— available <br /> Other within 200 feet.;Number �- <br /> of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. 0 Type/Mfg- Water table depth <br /> PKG. TREATMENT PLT, ❑ <br /> Capacity No, Compartments <br /> '. Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line - <br /> LEACHING LINE Cl No. & Length of lines <br /> FILTER BED Tota! length/size <br /> CJ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS PrDepth Size <br /> SUMPS Number <br /> I I Distance to nearest: Well fD0/ Foundation <br /> r <br /> DISPOSAL PONDS ❑ Property Line f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County t <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." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> RTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by <br /> Data Final Inspection by f <br /> Date <br /> Additional Comments- <br /> Applicant <br /> ommentsApplicant - Return all copies to: San J <br /> oaquia County Public Health <br /> I' <br /> Services, Environmental Health Permit/Services 5 <br /> f 1601 E. Hazelton Ave., P x 2009, Stockton, CA '95201 <br /> FEE <br /> INFO MOUNT DUEAMOUNT REMITTED CK DATE H RECEIVED BY , <br /> PERMIT'NO. <br /> . EH 13.24{REV,i:n ai <br /> EH 34.26 <br /> y Io�1� �fD-1733 <br /> r <br />