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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOA 2009, STOCSTON, CA 95201 <br />' PgMIm EXPIRES 1 YEAR FROM DATE IS ED <br /> (Complete in Triplicate) <br /> f' <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Servicees� <br /> lob Address ` �� '`� z City Lot Size/Acreage <br />' U`� t` .0}� Address <br /> Phoneh. '20 <br /> XOwner's Name <br /> Contractor Address PV1G License No. Phone_ <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> F ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [I Industrial ❑ Open Bottom F-1MantecaDia. of Well Excavation Dia. of Well Casing <br /> M Domestic/Prkyate ❑ Gravel Pack L1 Tracy Type of Casing Specifications <br /> I"1 Public Z fa Other rl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> I Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> i Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 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. 0 Method of Disposal <br /> ` Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/site <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size r — Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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, 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 10 wing: "I certify th in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compe.nsa- <br /> tion laws of ilornia.l. <br /> The applicant usl call 4orllIrsui, ins ctions. Complete drawing on reverse side. <br /> A(Signed Title: Date: ! <br /> I <br /> FO 15EPARTMENT USE ONLY <br /> Application Accepted by Date�^ Area <br /> Pit or Grout Inspection by Date Final Inspection by 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 AMOUNT DUE AMOUNT REMITTEDSH RECEIVED BY DATE PERMIT'NO. <br /> 'INFO <br /> F + EM 1�2�IREV. M sS 2 <br /> EH 1.1.20 c.J 1�J1 <br />