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` APPLICATION FOR PERMIT <br /> /( �J v, AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 4 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Pik 1601 E. HAZELTON AVE. , PHONE '(-209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <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 <br /> City !Lot Size/Acreage <br /> Owner's Name Address JS/ "^ Phone _ / <br /> i XContractor Address <br /> License Na, Phone <br /> TYPE OF WELL/PU NEW WELL 0 WELL REPLACEMENT D DESTRUCTION 0 Out of Service well 0 <br /> PUMP INSTALLATION C1 SYSTEM REPAIR 0 OTHER 0 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 /> E Industrial 0 Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing 5'"6ifications <br /> e <br /> p <br /> I'1 Public is Other 0 Delta Depth-of-Grout Seal, .- - Type"of Grout _ <br /> I I Irrigation —Approk. Depth f I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material b Depth ( - t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION' -(No septic system permitted if public sewer is <br /> Installation will serve: Residence` Commercial,,,` Other available within 200 feet.) l <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> PKG. TREATMENT PLT. 0 <br /> SEPTIC TANK. 0 Type/Mfg Capacit <br /> Y No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line , <br /> SEEPAGE PITS 11 Depth Sue t 'Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 taws, 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, <br /> tion laws of California." i shall employ parsons subject to workman's Compensa- <br /> The applicant must call for all required 'nspections. Complete drawing on reverse side. <br /> gful y� l <br /> Si nod Title: f'E `/J # <br /> Date: <br /> J FOR DEPARTMENT USE ONLY <br /> Application Accepted by _.Lk�w! % _ Date <br /> ---�_ Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <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 MOUNT DUE AMDUNT REMITTED <br /> N� <br /> INFO C SH RECEIVED BY PATE PERMIT"NO. <br /> a EH A-24{ftEV.t o sl a D <br /> EHA-26 <br />