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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONK t kiv* IE W <br /> 1601 E. HAZELTON AVE.. , PHONE (209}468-3420 <br /> P o BOX 2009, STOCKTON, CA 95201 <br /> PgMIT EXPIRES 1 YEAR FROM DATE ISNUM ENVIRONMENTAL ktALTH <br /> (Complete in Triplicate) PERMIT/SERVICES <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 couplience with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Address Address � <br /> Contractor Phone <br /> License No. Phone I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9 Monitoring Well €� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F) Industrial ❑ Open Bottom E3 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private L1 Gravel Pack "❑ Tracy' Type of Casing <br /> Specifications i <br /> C1 Public n Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation�— .Approx: Depth -t I Eastern- — Surface Seal Installed bye° <br /> Repair Work Done Type of Pump. H.P.f _ State Work Oona 'r <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth~' • 1xiller Material & Depth f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REP,AIRIADDITION { I DESTRUCTION 17 1Na tic system permitted if public sewer is <br /> t., + available within 200 feet.) <br /> installation will serve: Residence_ Commercial rOther <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. D Method of Disposal <br /> i <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size [� <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line l <br /> E <br /> SEEPAGE PITS l I Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation . Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and thatpthe work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San,-Joaquin'County.: -1 -'" <br /> Home owner or licensed agent's signature certifies the following: "I Certify that in the performance bf 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 subcontracting 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 applicant must call for all required inspections. Complete drawing on reverse side. <br /> k Signed X l �f l!p' �r62aw� •.-- Title: Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by AV <br /> Datego- <br /> a 6 <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> Additional Comments: <br /> 1 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 REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO GASH EM 13-Z4 iREV.t n si Q �^EH 14.2a 19/ <br />