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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 /> EXPIRES 1 YEAR FROM DATE MUED <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 Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address/D v �`t-� " City Lot Size/Acreage <br /> r <br /> Owner's Name Address Z V 7- A Phone o <br /> Coniracl r Address �, tJ� License No Z9 ZZ Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Uut of <br /> fService Well well I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 ❑ Manteca Dia. of Well Excavation Ria. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> CPublic 1-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —."Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> / available within 200 feet.) <br /> Installation will serve: Residence y Commercial— 0 t he& <br /> Number of living units: Number of b rooms ---- QO <br /> Character of soil to a depth of 3 feet: Water table depth O <br /> SEPTIC TANK TypelMfg CapacityyLiV 6 No. Compartments <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal <br /> Distance to nearest: Well= Foundation _. _ Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 1-I Distance to nearest: Well Foundation Property Line <br /> e� <br /> SEEPAGE PITS - Si Size Number <br /> r <br /> SUMPS LI Distance to nearest: Well Foundation /© Property Line .. <br /> DISPOSAL PONDS L1 <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 Caliomia.' <br /> The applicant mu all for all red spections. Completefdrewing on reverse/] <br /> Signed X �' Title: ` if� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date tel' r Area — <br /> PI or Grout Inspection by Date Final Inspection by <br /> Additional Comments: — <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Lnvironmental Health Permlt/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> 1 1 0" <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO /CASH <br /> Em13-2i IREV.i i N s)l -5 I, Hr � <br /> EH :4.26 <br />