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APPLICATION FOR PERMIT <br /> A' SAN JOAQUIN COUNTY 'PUBLIC HEALTH SERVICES CIC111 r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1 v 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOA 2009, _STOCKTON, CA 95201 <br /> EXPIRES 1=YEAR FROM DATE ED CU ,� <br /> PERMIT I 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 /> Job Address 0 Cit Lot Size/Acreage <br /> )( Owner's NamecAddress —sZ(,I ��Q A .��C� I, �`( Phone �(U <br /> Contractor Di(� Address License No. Phone_ <br /> PE OF WELL/PUMP: NEW WELL .❑ . _ :-WELL,.REPLACEM.ENT ❑ . DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION.O SYSTEM-REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK k SEWER�LINES-. DtSPOSAL,+LD. ' PROP. LINE <br /> FOUNDATION_ - AGRICULTURE WELL` OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1-1 Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing Specifications <br /> I') Public 1---1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation �.Approx. Depth ( I Eastern, Surface Seal Installed by. <br /> Repair Work Done O Type of Pump H.P. State Work Done <br /> C Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIONINo septic system permitted if public sewer is <br /> vailable 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 /> IIIJJJ PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Tota(length/size <br /> `\ FILTER BED ❑ 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 /> f� 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:"II cartify 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 work_man'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 persons subject to workman's compensa- <br /> tion laws of California."- <br /> The <br /> alifornia.The ap nt must c for alLrequi ed'inspeetions. Complete dra%AAing on,reverse side. <br /> t�$igned Title: 3 Date: <br /> � I <br /> FO_ _ eEPARTMENT USE ONLY S <br /> 4 Application Accepted by . Date C Area I <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 /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IN <br /> EE OU�N'T DUE AMOUNT REMITTED CK CASH RECEIVED BY DATES /PPERMIT'NO.� <br /> . EH13-211REV.iin5l U U _U '.1J <br /> EH 14-26 21-28 � q n,'' 15 <br /> ,,,, <br />