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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 BOX 2009, STtOCKTON, CA 95201 <br /> PFMIT I <br /> 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 of San <br /> Joaquin County Public Health Services. <br /> f <br /> Job AddressCity/ �f117 Lot Size/Acreage <br /> Owner's Name, '14P IL Address � Phone <br /> Contractor u ]L_ La—Address fC l.rd 9WF&%5 License No. i`'I C�/ Phone - t <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ EEE <br /> PUMP INSTALLATION . SYSTEM REPAIR ❑ OTHER ❑ 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 /> L� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _—.Approx. Depth 13 Eastern Surface Seal Installed by <br /> Repair Work Done U Type~ot Pump '.S1R��cesr�l6_ H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth fi <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDiTION I I DESTRUCTION I 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 x <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, LI Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size + <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS GI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 followlihg: ­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 applicant must call for all re3quiFed inspect �,7,, <br /> omple drawingZ <br /> �se side. <br /> -Signed X L i/ z Title: //�J r` •l Date: _ �� i /2 / <br /> F DEPARTMENT USE ONLY c <br /> Application Accepted by Date _ ` Area 2— <br /> Pit or Grout Inspection by Date Final Inspection by t Date <� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Ravironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEECK <br /> ��\\ <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> a EN 3.241REV.1/"51 AL�S .m <br /> EH 9426 n"IL �LLL ��� .G I J <br /> y F <br />