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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 <br /> PERMIT 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 <br /> Health Services. �j�� <br /> Job Address 7�/ <® ' � ? �� City'-„"� Lot Size/Acreage <br /> Owner's Name r` G� Address Phone <br /> Contractor , Address �-" License No�S24`7' Phone& r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION O 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) Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public (-I Other M Delta Depth of Grout Seal Type of Grout {� <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done O Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet. <br /> Installation will serve: Residence 1�Commercial ✓Other - � � _ Is � �� <br /> Number of living units: i Number of bedrooms_s�_s L ��� —"° <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK [f' Type/Mfg z' V C Capacity 3d-60 No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well�-LVo-Foundation - Property Line . <br /> LEACHING LINE E-r�No. & Length of lines c60 ' _Total length/size <br /> o?yo r <br /> FILTER BED O Distance to nearest: Well r Foundation r Property Line 220 <br /> SEEPAGE PITS 14`" Depth �� r Size C� _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line 0 / <br /> DISPOSAL PONDS O <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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic ust call or all req%ykeedgAsspections. Complete drawing on reverse side. <br /> Signed K _.�7`'�./ Title: C/YfVA.,fe�Z Date: Of <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by Date -2-)Z Area <br /> �it or Grout Inspection by Data (/ Final Inspection by Date ) T/ <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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATEt PERMIT'NO. <br /> + EH 13.24(REV.i/Rs) `/ k� — &f �Q 9a-- <br /> EH 262e 1 <br />