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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> L Z I 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> U P O BOX 2009, STOCKTON, CA 95201 V <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> e 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 /> Job Address P�yr.9cS�l� '� City <A"VrV\ - Lot Size/Acreage <br /> Owner's Name � Address 1(v ��ia )1_r Phone <br /> ContractorSake; Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Casing Specifications <br /> L <br /> ['I Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIONiNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <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. ❑ Method of Disposal ' <br /> Distance to.nearest: Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS - .-. ❑. - <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 Califor ' <br /> The applicant for re i ctions. mplete drawing on reverse side. OO <br /> Signed,X Title: Date: �`� 7� <br /> c <br /> O ENT USE ONLY ^� <br /> Application Accepted by Date Area 1 <br /> Pit or Grout Inspection,by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> IL 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FE <br /> INF MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI-f NO. <br /> r EH 13-21IREV.tx5) 35-00 Z7:�� �/0 <br /> EH A-26 ted, <br /> aQ-8 MAv rIn F Gid PP r, 5 w , EZ <br />