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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, STOCgTON, CA 95201 <br /> i <br /> PERMIT REP-JRES I YEAR FRPM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to $an 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 ' f ]� r- �>� „� City G Lot Size/Acreage <br /> Owner's Name n 6 ;+n 't(+ddress`' Phone _ <br /> Conttatior Address License No. oavJ Rhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E"1 DESTRUCTION C)-Out of Service ti✓e11 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> i DISTANCE TO°NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .PROP. LINE <br /> ` FOUNDATION AGRICULTURE WELL °"'OTNER,WELL 2` PITS/SUMPS <br /> } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> r <br /> f-1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Welt Excavation Dia. of Well Casing <br /> C:l Domestic/Private _❑-Gravel <br /> ._Pack _ .❑.Tracy__. Type of Casing t Specifications_U} <br /> i I'1 Publi6 !-1Other _In 1 Delta Depth of Grout Seal <br /> Type of Grout <br /> it Irrigation i —.Approx. Depth.,, I 1 Eastern Surface Seat installed by r <br /> I <br /> Repair Work Done; U Type of Pump - H.P. State Work Done <br /> Weil Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler;Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION d 1 REPAIR/ADDITION DESTRUCTION I i (No septic system permitted if public sewer is <br /> i E 1 ; available within 200 feet.) <br /> Installation will serve: <br /> I Residence�" Commercial_ Other <br /> � U k .fes. <br /> ! <br /> Number of living units: Number of bedrooms r ,, <br /> Character of soli'to-a­degth of 3 feetc Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments <br /> PKG. TREATMENT PLT. Ll Method of Disposal f <br /> Distance to nearest:i Well Foundation Property Line t <br /> LEACHING LINE <br /> P,"No, & Length of lines- —:L.- Total length/size <br /> FILTER BED 1-1 Distance to nearest: WellI Foundation + <br /> - �_..____ Property Line I An i <br /> I SEEPAGE PITS. IJ Depth Size �_ _���`_ Number <br /> SUMPS <br /> Distance to nearest: Well Foundation _ Property Line�, <br /> DISPOSAL PONDS ❑, <br /> i I hereby certify that ! 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 C& <br /> un <br /> Home oinrner or licensed agent's signature certifies the following; "f;certify that lin-the performance of the work for which this permit is issued, I shalltlnot <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 /> i cerli}ies.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 compej sa- <br /> tion laws of California." <br /> The applicant must call,for all requ'ed inspections. Complete drarv"riig Zn reverse aside. <br /> Signed <br /> -•-._ Title:. - YL t r- - -Date:. <br /> „ R DEP RTMENT USE ONLY <br /> Application Accepted by Date �' Area <br /> Pit or Grout inspection by Data Final Inspection b Date . <br /> Additional Comments: <br /> Applicant - Return all.copiee to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUEAMOUNT REMITTED, CK RECEIVED'BY DATE PERMIT'N0. <br /> INFO CA-SH, <br /> EH 11241REV.iiK51 ' o`= <br /> EH 14-26 - <br />