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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV I RONMENTAL HEALTH DIVISION a�� <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> aA ` P O BOX 2009, STOCKTON, CA 95201 <br /> ;JJ 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 Health Services. <br /> Job Address T"7i L.�-----�C.� City �jACI_� Lot Size/Acreage <br /> Owner's Name Address hone <br /> Contractor ddress License No. Phone <br /> TYPE OF WELL/PUMP: N W WELL 0 WELL REPLACEMENT ❑ DESTRUCTIO Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well 0 <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 /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> t1 Public (:1 Other f 1 Delta Depth of Grout Seal Type of Gr <br /> I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump 6,4w H.P. _qtate W rk Do e <br /> Well Destruction Well Diameter /_ 0 Sealing Material A Depth <br /> Depth !OJQ Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 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. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Methbd of Disposal <br /> Distance to nearest: Well Foundation Property-Line Q <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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, an <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, 1 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 applics u It all r rred ns. Complete drawing on re e side. <br /> Signed ills: Date: <br /> ENT USE 0400Y <br /> Application Accepted by Date 2- Area <br /> Pit or Grout Inspection by Date Final Inspection by �J Data�r <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 -95201FEE <br /> - -- <br /> INFO A UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 132/JpEV.1/851 ���� �j��� �� C� 9�_' <br />