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m. 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, STOCETON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRQM-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 Ban Joaquin County Ordinance No. 51+9 nd 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se ices. <br /> Joh Address Size/Acreage <br /> ner's Nam Address Phone <br /> Cc trac r ress ;21, ,y icense No. ?"/w Phone <br /> TYPE OF WELL/PUMP: NEW WEL ❑ _WELL REPLA EMENT ❑ DESTRUCTION ❑ Out of Service Well El <br /> PUMP INSTALLATION SYSTEM REPAIR © OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLO. PROP. LINE <br /> FOfJNDAT*N AIWOCAJUTURE OT+fER-WELi * 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 /> C] Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'3 Public fife Other f� Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation I_.Approx, Dep I I Eastern uriace Seal installed by ! <br /> Repair Work Done L1 Type of Pump�w H.P. State Work Done <br /> Welt Destruction ❑ Well Diameter Sealing Material & Depth p� <br /> Depth ,'% 7 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted it public sewer is <br /> i <br /> available within 200 feet.l ; <br /> installation will serve: Residence_ VCommercial'_ Other:! <br /> Number of living units: Number ofJ'bedr`ooms i <br /> - � ";{�f "' .,_.,._. ,..,_.._ <br /> SEPTIC TANK ❑ Te/Mi � <br /> Character of soil to a depth of 3 feet: Water table depth <br /> - J <br /> YP 9 Gapacity No. COrnpartments <br /> PKG. TREATMENT PLT. � Method of Disposal <br /> Distance to nearest: Foundation Property Line <br /> I ; <br /> LEACHING LINE I No. & Length of lines Tata! length/size <br /> FILTER BED C1 Distance to nearest: Well Foundation' Property Line; <br /> SEEPAGE PITS I Depth Size r ' f f Number <br /> SUMPS [. Distance to nearest: Well oun ation _ Property Line <br /> DISPOSAL PONDS Ej <br /> I hereby certify that I have p par is application and t attil-ieTwork`wi be done in accordance with San Joaq in county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed a eng is signature certifies the followsrig:_"Lcartity-jbat itLtbB-wrf.otmanre-atlhe-.wo&Jor-Lhich-ttti"etmit-is-issued,-I-shall not 1 <br /> emplo many peraon,in such.mannar as to become subject to workmen's.compensation laws of California." Contractor's hiring or sub contracting signature <br /> eertifies the fotlovvirig !certify that in the perfbrmancej)Nlhe work fnr-which this permit is issued, I shall employ persons subject to workman's compensa- I <br /> tion laws of C 'fornia."' <br /> The appl'Ic t st ca for quire inspections. Complete drawing on re se side. <br /> Si a Ti Date: <br /> I <br /> =S))- NT USE ONLYAppiicatton Accepted byDale-_ _�-g^cl�t Area <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by� DateQ <br /> E Additional Comments: <br /> F <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK3H RECEIVED BY DATE PERMIT'N0. <br /> . EH1824IREV.1)N51kQ_CH t4.2e . <br /> ice. <br />