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{ APPLICATION FOR PERMIT <br /> I � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION a S. <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> 4;;. <br /> i P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT 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 /> 1117t <br /> Job Address giUZ City hot Size/Acreage <br /> f_ <br /> Owner's Name ddress _ Phone - f <br /> Contractor &"-Ss .�hnse No. Y_KZPPhone <br /> TYPE OF WE L/P P: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ( n <br /> f"1 Public Cl Other n Delta Depth of Grout Seal Type of Grout V <br /> I i Irrigation —,.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pum H..P — - State Work Done _ <br /> Well Destruction ❑ Well Diameters Sealing Material & Depth <br /> Depth Filler Material Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I (No stem septic s permitted if <br /> P Y P public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence 1 Commercial T Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet: A 0=4 Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I '�- f 5 5 f Method of` iosal <br /> Distance to nearest: Well Foundation 17 6 Property Line �/' <br /> .4 <br /> LEACHING LINE Cl No. & Length of lines ` - Total length/size ►J <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth ! Size Number <br /> SUMPS Ll Distance for nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 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 taws of California." i <br /> The applicant u II all r ire inspections. Co eta drawing on reverse side. <br /> Signe4 Title: _ <br /> pate: l <br /> O EPARTMENT USE ONLY <br /> Application Accepted by Date 2� Area <br /> Pit or Grout Inspection.b-yrt Date 1^ Final Inspection by x.1.1 Date Z 1 y <br /> Additional Comments: t`�•S r S CZ '��c� ot- 5eycc, .e� 'Fr,,—�C-,-� �s. { <br /> Applicant - Return all copies to: 4-Y T, <br /> !$an 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 CKRECEIVED HY DATE PERMIT'NO, r <br /> INF CASH <br /> EH 13-24(REV.iixsl 1 (} <br /> 8H t3-2e [ �y tel.l! �lC <br />