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APPL I CATION FOR PERS{I T <br /> �1 SAN JOAQUIX COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I <br /> P9MIT 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 a <br /> gu of' San <br /> Joaquin County Public Health Services. <br /> Job AddressCit 7 Lot Size/Acreage <br /> Owner's Name Address - ! Phone <br /> 1 Lam' 2 f ; <br /> Contractor Address <br /> LIC@nye No, hone <br /> TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C] <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 /> F1 Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> f7 DomestielPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public Cl 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 0 Type of Primp H.P.` - State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material epth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 14 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> ' available within 200 feet.i <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of$feet: Water table depth <br /> SEPTIC TANK '• ° ❑1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> i Distance to nearest: Well Foundation Property Line <br /> 3 <br /> LEACHING LINT: Cl', No. & Length of lines 1AQ Total length/size t <br /> FILTER BED Cl Distance to nearest: Well n ion Property Line <br /> SEEPAGE PITS i It Depth Size Number <br /> e�7 ` } <br /> SUMPS 111 Distance to nearest: Well tion Property Line <br /> DISPOSAL PONDS L3 ! . �(/` <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 /> Home owner or licensed agent's signature certifies the following: H <br /> g 9 g: "k certify that in the performance of the work for which this permit is issued, !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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must c ll fo requir� tions. Compf to yawing on reverse-iid.%, <br /> �^y l <br /> Signed X ' Ily Title: ( Date:KI� <br /> t <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by 1J, Date e <br /> Area <br /> Pit or Grout Inspection by Date final Inspection by a;e�a F <br /> i <br /> Additional Comments: - _ <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services .i <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IN AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT'NO. <br /> + EN 3-24 EH 7/"20(REV.1/951 <br /> s <br />