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APPLICATION FOR PERMIT <br /> O 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 /> 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 j� .4�.C��.J[M � City - Lot Size/Acreage , " <br /> r <br /> Owner's Name Add res <br /> Phone % �3 "I <br /> Contractor <br /> e_ Address r� License Nr 3LZ Phone A6C� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IDDESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION O 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 /> f] Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public 1.1 Other n 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 U Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth d e <br /> Depth Filler Material & Depth N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION lir DESTRUCTION 11 (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence V, Commercial_ Other <br /> Number of living units: 4— Number of edrooms— <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 111,—No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well a Foundation n10 r Property Line G f <br /> SEEPAGE PITS W4---Depth -Size r Number <br /> SUMPS Ll- Distance to nearest: Well Foundation 10 ' Property Line /0 f <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 subcontracting signature <br /> certifies the following:,-`f certify that in the performance of the work for which tjhis>permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The appl t must call for all re red ' s¢ections. Complete drawing on reverse side. <br /> Signed Title:er�i•We�f Date: �-�f f/ <br /> FOR DEPARTMENT USE ONLY [� <br /> Application Accepted by Date J '' Area 2- <br /> Pit or Grout Inspection by Date Final Inspection by Date �Z <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 AMOUNT DUE AMOUNT REMITTED CK REC ED BY DATE PERT'NO. <br /> INFO CASH MI/ <br /> + EH 13.21(REV y �/ yc 71 <br /> EH b2e <br />