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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION O <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 A&/ <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> RES 1 YEAR FR M DATE ISSUED <br /> rr�—s,fR <br /> (Complete in Triplicate)Application is hereby made, u Joaquin County for a permit to construct and/or install the Work herein described. This <br /> i application is made in compliance with San Joaquin County Ordinance No. 549 and 18 2 and the Rules and Regulations of San <br /> Joaquin Count b He h Services. <br /> Job Address �7 <br /> !� 1 City Lot Size/Acreage <br /> Owner's Name Address Phone <br /> s 4+F <br /> Cor+trattor Address r icense No�:J Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE M TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q <br /> ` r Type of Casing Specifications <br /> C�:l Domestic/Private ❑ Gravel Pack ❑ Tracy YR 9 <br /> i'1 Public EI Other n Delta Depth of Grout Seal Type of Grout r ft <br /> "J <br /> i I Irrigation —,.Approx. Depth I I Eastern Surface Seal Installed by _ <br /> ! ' H.P. State Work Done <br /> Repair Work Done (7 Type of Pump (� <br /> ' Well Destruction O Well Diameter Sealing Material & Depth <br /> r Depth t Filler Material & Depth <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIOIND septic system permitted it public sewer is <br /> ailable within 200 feet.) <br /> 1 Installation will serve: Residence' Commercial_ Other _ " <br /> AZ <br /> Number of living units �Type/ <br /> Number of bedrooms Y <br /> Character of soil to a dof 3 to r table depth <br /> SEPTIC TANK Mfg.• Capacity -- No. Compartments <br /> �- <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance.to nearest: Well n Property Line <br /> LEACHING LINE Ia No. & Length of lines Total lengt <br /> FILTER BED 0 Distance to near Well Foundation Y Property Line <br /> SEEPAGE PITS [ I . Dept Size Number <br /> SUMPS 1 1 D' ance.to nearest: Well Foundation Property Line--- <br /> DISPOSAL <br /> ineDISPOSAL PONDS <br /> I hereby certify that I ha 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 Ahe San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "i certify that in the perf8►mance 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 lewa of California."Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance o e work for which this permit is issued, I shall employ persons subject to workman's compensa +� <br /> I tion laws o aiifor ' ; <br /> The appli t all I q 'e f petition C late drawing n er side. <br /> Signed �" Tit1 %_ Date: <br /> I FOR D RTMENT USE ONLY <br /> Application Accepted by ' Date - - Area <br /> t <br /> Pit or Grout Inspection by ! Data Final Inspection by Date <br /> Additional Comments: 11 I�i 1i Ili �/i4 I/ CONI a�f�tGC. 6'1(G. r� G <br /> c <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Bovironmental Health Permit/Services � (� <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKCASH RECEIVED BY DATE PERMIT'NO. <br /> IN <br /> a EH13.2iIREV."51 <br /> EH 34.20 <br />