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/ »` APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> { 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> ZA tl_ <br /> P 0 BOR 2009, STOCKTON, CA 95201 N <br /> N <br /> *+*'AUTT EgpTRES 1 YEAR FROM DATE I2SUED `rQ , <br /> (Complete in Triplicate) <br /> Regulations Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein descried. s <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and of San 4tian <br /> Joaquin county Public Health Services. 1 <br /> 3 Z 3 t� J? S ��� City <br /> ob Address 2 3 t Size/Acreage <br /> J � �ddress 7 22% <br /> ty�� <br /> e / one �3 g . <br /> rOwner's Name f I <br /> Contractor Address ��� `-� <br /> License No._____.----Phone_ <br /> NEW WELL ❑ ELL REPLACEM T ❑ DESTRUCTION out of Service Well ❑ <br /> TYPE OF WELL/PUMP: OTHER ❑ Monitoring Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM PAIR ❑ <br /> SEWER L ES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK t� <br /> FOUNDATION AGRICUL RE L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS Dia. of Well Casing ^, <br /> ❑ Open Bottom ❑ Manteca is. of Well Excavation V <br /> Cl Industrial Specifications <br /> T pe of Casing <br /> O Domestic/Private ❑ Gravel Pack El Tracy D th of Grout Seal Type of Grout <br /> I'l Public (.1 Other n Delta <br /> I I Irrigation _.Approx. Depth I I Eastern Su ce Seal Installed by <br /> P State Work Done, <br /> Repair Work Done U Type of Pump Sealing Mate sl & Depth <br /> Well Destruction ❑ Well Diameter Filler Materi & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTIO (No septicailable ssystem permitted <br /> itted if public sewer is <br /> Installation will serve: Residence X Commercial 2 Other____ r v n <br /> Number of living units: : Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED Cl Distance to nearest: Well Foundation P Y <br /> Size _ Number <br /> SEEPAGE PITS Ii Depth property Line <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I her 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 /> ollowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the f <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring <br /> u orkman's9omnature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ pesubject <br /> tion laws of California." <br /> The applicant must call forall <br /> required inspections. Complete drawing on reverse side. 3^ _ C <br /> kigned <br /> Title: ) Date: <br /> X <br /> �OR EPIENT_.USE ONLY <br /> Area <br /> Date <br /> Application Accepted by -D ate <br /> Final Inspection by D <br /> Pit or Grout Inspection by Date ) <br /> If <br /> Additional Comments: <br /> ��-'d <br /> Applicant - Return all copies to: San Joaquin County Public liea `^( <br /> Services, Environmental Health Permit <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> OUNT DUE AMOUNT RE7HCASHINFO2EH 13.24(REV.i i n 5) �� J �, <br /> EH;1.26 <br />