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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 85201. <br /> WIT EXP RES 1 YEAR FROM D E ED <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 Ordinanc No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> OF <br /> Job Address <br /> City Lot Size/Acreage <br /> I <br /> Owner's Name ddress <br /> Phone <br /> Contractor �fv ess <br /> ease Na Phorte <br /> TYPE OF WE L P P: NEW. LL © WELL REPLACEMENT ❑ <br /> DEST U TION CI <br /> of ervice Well Q <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C) Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br /> f7 Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> C7 Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> E) Tracy ,Type of Casing <br /> I') Public L] Other , Specifications <br /> FI Delta Depth of Grout Sea[ Type of Grout <br /> I I Irrigation _...•_Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. (� t <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth , V <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I l DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence !/ Commercial_ Other available within 200 feet.) <br /> Number of living units: —I— Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ , type/Mfg Capacity Compartments <br /> PKG. TREATMENT PLT, ❑ ) <br /> Method of Disposal <br /> Distance to nearest: Well Founclationl-I 1d Property Line <br /> LEACHING LINE ❑_. 14. <br /> r <br /> No. & Leng;h of lines 1 <br /> FILTER BED Total length/size <br /> [1 Distance to nearest; Well ���Foundation �_ <br /> Property Lina <br /> SE AGE PITS I 1 Depth � Size <br /> Number ` <br /> Ll Distance to nearest: WeII � Q <br /> Foundation-/ Propertyne.Li <br /> DISPOSAL POND5 p - ,�. � <br /> I hereby certify that t have prepared'this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, aXd <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, 1 shall employ <br /> tion laws of California." p p Y persons subject to workman's compensa- <br /> tion <br /> applicant njust call far all requir ns ctions. Com et rawing on reverse side. <br /> Signed Title: ' <br /> Date: <br /> FOR TM "NT USE ONLY <br /> Application Accepted by ,G_ ��± ~~ Ct <br /> __ Date L Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date r <br /> Additional Comments: <br /> Applicant - Return all cop ies"to.—San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services � L <br /> 1.601 E. Hatelton Ave., P O Box 2009, Stockton, CA 95201 rA <br /> FEE MOUNT DUE AMOUNT REMITTED CK F <br /> INFO CASH RECEIV S BY DATE- PERMtT'NO. <br />+ EH 24 TREY.r i x Si y J� <br /> EH Ai�-ffi <br />