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L APPLICATION FOR PERMIT Ki <br /> SAN JOAQUIN 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 /> PERMIT EXPIRES ]. 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 Jo in County- ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ° City kklLot Size/Acreage <br /> Owner's Name � `S ddress v Phone <br /> Contractor � � Addles License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCETO'NEAREST: SEPTIC TANK — - —SEWER LINES .. -DISPOSAL• FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [_-1 Industrial; ❑ Open Bottom ❑ Manteca. Dia. of Well Excavation Dia. of Well Casing <br /> [.l Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing = Specifications <br /> I'I Public 3 Cl Other A Delta Depth of Grout Seal # Type of Grout <br /> t I Irrigation! �Approx. Depth I'I Eastern Surface Seat Installed by F <br /> Repair Work Done 0 Type of Pump H.P. State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth t <br /> ° Depth Filler Material S Depth { <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 3 -REPAIR/ADDITION TRUCTION [ I (No septic system permitted if public sewer is /r <br /> : 11s available within 200 feet.) <br /> Installation will serve: Resi encs.—L—Gemmercial_ her <br /> !Number of living units: Number of edfooms�- <br /> x <br /> Character of soil to a depth of 3 feet: �� Water table depth <br /> SEPTIC TANK. 0 Type/Mfg _ _�;i,(Ty fZ� Capacity--.,f�5 No. Compartments <br /> PKG. TREATMENT PLT.'GI ` Method of Di os� <br /> Distance <br /> to nearest Well _�� Foundation Ptoperty Line _ j <br /> � I <br /> I <br /> LEACHING LINE GlL- l,. & Length of lines TorI length/size <br /> FILTER BED ❑ Distance to nearest: Well. Foundation -, r� Property Line <br /> SEEPAGE PITS h Size _ _ umber } M <br /> SUMPS a Ll Distance to nearest: Well Foundation / Property Line <br /> DISPOSAL PONDS ❑ j <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 4 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perforfTnance 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 taws of California.', Contractor's hiring of 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 app�trmn call for all equ' dins ctions Co p awing reverse side. + <br /> l a <br /> 4 <br /> SI b ~� <br /> nle Date: ' <br /> FOR DEPARTMENT USE ONLY d # <br /> Application Accepted by OvwData Area <br /> Pit or Grout Inspection by - Date Final Inspection by Date�� y <br /> 2 !! <br /> Additional Comments: L /32 7'6 1 . <br /> 1 G f� <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> ,..,..Ser-vices,-Environmental-.Health.-Permit/Services— - - -- <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE 1 <br /> INFO AMOVN/T�pVk AMOUNT REMITTED CASH RECEIVED BY DATE PERMn'NO. 1 <br /> . <br /> EM1-24 TREY,Iinsl <br /> EH 14.2e L rn� j3 1.14-25 <br /> ✓t� l CC.�� <br />