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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f�a�. I} <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> pgRUIT EXPIRES 1 YEAR FRPM DATTIOM <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 /> ' <br /> C SCQ 1 <br /> Job Address 6 sef dnQl— - - City Lot Size/Acreage Q <br /> f� Phone v ��� ��� <br /> Owner's.Name e I �' ` t Address <br /> Contractor <br /> pu1h����9dress 1�f�� Q License No., Phone -0 1 <br /> TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll <br /> SYSTEM REPAIR ❑ OTH•ER C� Monitoring Well [I <br /> PUMP INSTALLATION � 1 ) I <br /> DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES/ DISPOSAL FLD. . d PROP. LINE/t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS N_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial e ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. at Well Casing <br /> Domestic/Private X Gravel Pack 0 Tracy Type of Casing Specifications <br /> — <br /> Domestic/ <br /> Public Cl Other F1 Delta Depth of Grout Seal IU12 Type of Grout <br /> I I arrigapon Approx. Depth I I Eastern Surface Seal Installed by , f <br /> Repair Work Done 0 Type of Pump 4kbm H•P• State Work Done i <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I 1 INailabetic system <br /> ithin m rmitjed if public sewer is v <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms, <br /> Character of soil to a depth off,3 feet: Water table depth ` <br /> SEPTIC TANK ❑ Type/Mfg t -�-""Capacity Na. Compartments <br /> PKC. TREATMENT-PLT.Cl T ��� Method of Disposal <br /> C ...Distance to nearest: Well Foundation �`� Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' <br /> FILTER BED t r!„ Distance to nearest: Well Foundation Property Line f <br /> rF <br /> SEEPAGE PITS l I Depth Size ' _ Number <br /> SUMPS 5 Ll 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 regul4tions 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: '4 certifythaain-the-performance'of the'work-for whitA-thh permit ivissusd;"I'iihiIl'employ persons subject to workman's compensa- <br /> tion laws of Californla." <br /> I The applicant- st call lir all required ins ,crtions. Comple rawing on reverse side. . <br /> l f �''" Title Date: <br /> Signed <br /> FOR DEPARTM NT USE ONLY ` rr <br /> Application Accepted by Date ` Ar <br /> Pit orOWL <br /> Inspection by Dat.-,-Z Final Inspection by ZZ <br /> Date <br /> t <br /> i <br /> Additional Comments:_. <br /> :.'Applicant - Return all copies to:1. San Joaquin County Public-Health <br /> Services, Environmental Health Permit/Services <br /> - :1601 E. Hazelton Ave., P 0 Box 2009, Stockton,'_CA 95201 <br /> 11 <br /> FEE AMOUNT Dili'- AMOUNT REMITTED CK RECEIVED BY DATE PERMIT�No, <br /> INFO CASK <br /> '70 - `4 7 W <br /> a EH 13.24 IREV. n 51 ' �.� S� �� 'a Z 0— V <br /> EH 14.26 r <br />