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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZFLTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> J (Complete its Triplicate) <br /> 1 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 /> e <br /> Job Address i <br />. Git ,_.,,_ Lot Size/Acreage <br /> Owner's Name _. C J� {7� Address Phone <br /> Contractor-. Address_:' - � ��U"�"/ <br /> License No. Ph <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION Cl Out of Service Well ❑ <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 e <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C..l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public (a Other I ❑ Delta Depth of Grout Seat Type of Grout <br /> r <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction © Well Diameter, Sealing Material & DepthP s` - <br /> � <br /> Depth <br /> � Filler_,iNterial & P x— <br /> aDepth ,t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-1 I—REPAIWADDITIO_ _.-."DESTRUCTION 1,I,fNo septic system permitted if public sower is <br /> -------- a. ,,- -�.�. - � � � available within 200 feet.) <br /> h Installation will serve: Residence_ Commercial -OthTr"— <br /> k Number of living units: Number of bedrooms d <br />` Character of soil to a depth of 3 feet: t Water table depth <br /> SEPTIC TANK. © Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. CI­,ta <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHtNG LINE ❑• No.A Length of lines Total length/size <br /> FILTER BED (J� r l <br /> HCl �Distance to nearest: Well Foundation __ l� Property Line <br /> SEEPAGE PITS" Depth e Nupber <br /> SUMPS Distance to nearest: Well / Foundation Property Line JQ <br /> DISPOSAL PONDS -0 f <br /> I <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 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 m 11 for all required in ions. Complete drawing on reverse-side, <br /> Signed X Title Date: O <br /> FOR DEPARTMENT USE ONLY J <br /> Application Accepted by <br /> Date C Area <br /> I <br /> Pit or Grout Inspection by :iDate Final Inspection bq_ Dates U <br /> Additional Comments: <br /> Applicant - Return all copies to: .San Joaquin-County Public Health r - <br /> 1Services, Envir6nmental Health Perttsit/Services <br /> X1601 E. Hazelton Ave., P 0 Box 2009; Stockton, CA 95201FEE <br /> INFO AMOUNT DUE S AMOUNT REMITTED CK 9 RECEIVED BY <br /> CASH DATE PERMIT NO. i <br /> fr - - - - . <br /> a EH 13-24 1REV,I/x 5! g-A __76, <br />