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'IyQ APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y <br /> ENVIRONMENTAL HEALTH DIVISION , <br /> 1601. E. HAZELTON AVE. , PHONE (209)468-3420 <br /> IP O BOR 2009, STOCKTON, CA 90201 <br /> %P RES 1 YEAR FRPM DAT <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 /> City Lot Size/Acreage <br /> Job Address <br /> �� Address <br /> Owner's Name <br /> Phone ` <br /> Address� ' `" �' ' pt License No. Phone <br /> Contractor <br /> TYPE Of�WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> OTHER D Monitoring Well <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ it <br /> DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Wel! Casing <br /> n Industrial E) Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications I <br /> C:1 Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> Il Public I:1 Other 9 11 Delta # Depth of Grout-Seal <br /> I I Irrigation _Approx.�Depth I i Eastern � Surface Seal Installed by I <br /> H.P. State Work bone — <br /> Repair Work done ❑ Type of Pump Sealing Material &'Depth <br /> Well Destruction U Well Diameter, *l ,; <br /> Depth Filler Material fi Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION^. DESTRUCTION I I (No <br /> lseptic within system tmfeetit`ed it public sewer is <br /> F f <br /> t I <br /> Installation will serve: Residence *K# Commercial— Othe'r <br /> Number of living units: Number of bedrooms — �w - - <br /> i Water table depth Ln <br /> Character of soil to a depth.of 3 feet:. ;-, <br /> SEPTIC TANK. D TypelMfg f �C6 c Capacity >!jNo. Compartments <br /> PKG. TREATMENT PLT. ❑ 5 Method of Disposal <br /> Distance to nearest: Well I�- - foundation�� - Property Liner_�— <br /> i � - <br /> LEACHING LINE 0 No. & Length of lines <br /> Total length/size <br /> FILTER BED C! Distance to nearest: Well Foundation Property tine <br /> SEEPAGE PITS 11 .Depth Sire Number <br /> SUMPS LI Distance to nearest: Well r Founhation Pr p rty Line <br /> DISPOSAL PONDS 1:1 <br /> I hereby certify that I have prepared this application and that the work will be done in accofdance 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 <br /> '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 comper4ation laws of California Contractors hiring or 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 parsons subject to workman's compensa- <br /> tion taws of California." vR E <br /> The applicant must call for all required inspections. Complete drawing on rever�de. <br /> 4 Title: - ue 3. ASS°9't'� <br /> Signed X <br /> q FOR DEPARTMETIT USE ONLY <br /> t � <br /> Application Accepted by Date �' CI Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> . Applicant - Return all copies to, Ban Joaquin County Public Health <br /> Services, Environmental Health-Permit/Services <br /> 1601 E. Hazelton Ave., p 0 Box 20t]9,�Staaton, CA\ 95201 <br /> FEED DUE AMOUNT REMITTED H RECEIVED BY DATE PERMI7'NO. <br /> INFO <br /> a EH 13.24IREV.1/Hw r O-D jn , 3 O <br /> EH .4-20 <br /> i - <br />