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M <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION * � i'11,11E <br /> 1601 E. HAZELTON AVE. , PHONE (200468-3420L , <br /> ,W , <br /> P O BOX 2009, STOCKTON CA 95201 APR ' 1091 <br /> EMIT EXPIRES 1 YEAR FROM DATE ISSUEDt-NVIRG.NMENTAL HEALTH <br /> (Complete in Triplicate) <br /> PEERMIT/SEkv;C►�S <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 Q City 6-ZC Lot Sise/Acreage <br /> C <br /> Owner's Name AddressQQ. r Phone <br /> Contractor / Address , License NoJ —j_Phon VZ4" <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION Cid" SYSTEM REPAIR, O OTHER O 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 /> C) Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> I'1 Public 1l Other n Delta Depth of Grout Seal Type of Grout <br /> Irrigation Approx. pepp I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump • H.P. I d State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material& Depth: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it 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. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Lira <br /> SEEPAGE PITS 1 1 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, and <br /> rules and regulations of the San Joaquin County. <br /> Homeowner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shah not <br /> employ any person in such manner as to become subject to work*isn's compensation taws of Califorrtit."-Contractor's hiring or sub-contracting signature <br /> certifies the following:"1 certify that in the performance.of the work for which this permit is issued,1 shalt employ persons subject to workman's compensa- <br /> tion laws f California." <br /> The applic must call for all quired inspections. ComplUpdrawing reverse side. <br /> Signed Title: Date: 3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t+ Date Area <br /> Pit or Grout Int1ts: <br /> ion by Date Final Inspection by"a-" "` �-- > Dat G tl/ _ <br /> Additfonsl Com <br /> Applicant —Return all1copies 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 RECEIVED BY DATE PERMtT'N0. <br /> 'H 18.24 IREV.iina PR �� Q <br /> H 11.211 l <br />