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APPLICATION FOR PERMITn �� r <br /> 4 <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES -i <br /> ENVIRONMENTAL HEALTH DIVISION N <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 OWAK <br /> P 0 BOX 2009, STOCKTON, CA 95201 N YZZ <br /> PERMIT EXPIRES I YEAR FROM 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> S <br /> erv <br /> ices. <br /> Job Address _ ` G !i City Lot Size/Acreage <br />� t � - Address _ Phone <br /> Owner's Name _ -� _ <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well <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 /> I'I Public El Other � n Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation —.Approxi Depth f I Eastern Surface Seal Installed by <br /> Repair Work Done IJ 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 DESTRUCTION INo 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 bedroo s <br /> Character of soil to a depth of 3 feet j ter table deptIT FYPh <br /> SEPTIC TANK. te TypelMfg MUD <br /> No. Compartments44 <br /> PKG. TREATMENT PET. ❑ �� may MUD Oy; rOd withoVt Method of Disposal <br /> Distance to nearest: weLine <br /> LEACHING LINE L] No. & Length of lines i i=1 vi 'i l• si <br /> �9 ���fe�l�size <br /> FILTER BED [J Distance nearest: Well Foundation Property Line <br /> i <br /> 'SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance io nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 i <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 ton's compensation taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that int rformance of thw work or which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of Californi <br /> Thea applicant must all for re uir l <br /> PP q pectin to wI on reverse side. c <br /> Signed X Title: Date: <br /> R qWAFITMENT USE ONLY Q <br /> Application Accepted by µ Date ` Area <br /> 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/Serviees <br /> 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE A UNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH13-21(REV.119si f <br />