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APPLICATION FOR PERMIT iL7-) <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> lfl 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 <br /> pHealth <br /> . Services. <br /> �C �l <br /> Job Address L-iA.��h, CityLot Size/Acreage <br /> �� <br /> 1 M ,i��= �L►7 i.>>,.0 Address/ 7 �c►.1L /L i� Phone / d <br /> Owner's Name – ,/ / <br /> Contractor <br /> �% �C rpt 1�,' Address 7`C :�. License NW� . 3 7 -Phone 2 <br /> TYPE OF WELL/PUMP: NEW WELL �?, WELL REPLACEMENT n- DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ' SYSTEM REPAIR ❑ 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 /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excav ° Dia. of Well Casing <br /> Domestic/Private VGravel Pack El Tracy Type of Casing /'�_4j_,1 Specifications <br /> 1'I Public 1-.1 Other n Delta Depth of Grout Seal r _ 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 <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 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 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 ❑ <br /> 1 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 California." <br /> The applicant Vust cII for all regyired inspections. Complete drawing on reverse side. <br /> Signed X { -Title: Z Date: <br /> FOR DEPARTMENT USE ONLY g <br /> Application Accepted by Date _ ` 0 _rea / <br /> Pit or Grout Inspection by Date Final I/�ec'on by Date' <br /> Additional Comments: <br /> Applicant – Return all copies to: San Joaquin County Public Health f/� F� / <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 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH t1 <br /> . EH 13.21(REV.r/R5) 1 L/ (7 0 <br /> EH 2141 1 <br /> o- 1773 <br />