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' f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> -Rein 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DATE ISSUR <br /> (Complete in Triplicate) <br /> Application is hereby made,to San:ioaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance;4ith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servides. <br /> AO-V y c _ City Lot Size/Acreage <br /> Job Address A <br /> Owner's Name <br /> Address Phone <br /> Contractor, v Address License No. Phone <br /> TYPE OF�WELL/PUMP: NEW WELL C7 WELL REPLACEMENT C1 DESTRUCTION ❑ Out of ervice Well <br /> Monitoring Well 7 <br /> � PUMP INSTALLATION ❑ SYSTEM REPAIR 14 OTHER ❑ <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 /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C} industrial ' r / <br /> Domestic/Private 0 Gravel PackY Ll Tracy Type of Casing Specifications <br /> I'I Public ; 17 Other y� n Delta Depth of Grout Seal <br /> { Type of Grout <br /> I I Irrigation Approx. Depth l I Eastern Surfalce eal-Installed-bye <br /> Repair Work Done j$ Type of Pump ( H•P• State Work.Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material &'Depth-1t 3 <br /> Depth Filler Material A Depth r.. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> — -r- availablewithin 200 feet.) <br /> Installation will serve: Residence Commercial ' Other _ <br /> Number of living units: Number of bedrooms T <br /> �'` ' .3 <br /> Character of soil to a depth of 3 fee :_ Water table depth <br /> I <br /> SEPTIC TANK EIType/Mfg t Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ; ': `* Method of Disposal <br /> Distance to nearest: Well Foundation Property Linty <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance Well-m:j. Foundation Property Line <br /> l <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <br /> 1 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 /> cartifies 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 taws of California." <br /> i The applicant must for aft required inspect• S. Co ete drawing on re rse side. <br /> Signed X Title: . Date: <br /> I a�--�DE�PARTM�ENTUSE�ONLY <br /> it <br />` Application Accepted by 0. ' Date `�`� Area <br /> Pit or Grout Inspection by Date Final Inspection by � � Date t y7 <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 /> IFEE NFO AMOUNT DUE `n ;AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. <br /> ip{ a EH 13.241REvA/R31 ��[� f <br /> EH 14'26 N <br />