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a 5 <br /> APPLICATION FOR PERMIT <br /> - . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH bIVISION �. F <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 , <br /> P O BO% 2009, STOCKTON, CA 95201 <br /> ' , a 4r'4 <br /> PEMIT <br /> t t <br /> _EXPIRES 1 YEAR FR M DATE A j: <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.�T This z t <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules,aaii Regulations of San; <br /> Joaquin County Public Health Services. <br /> City yjLot Size/Acreage j <br /> .fob Address <br /> Phone � <br /> Owner's Name d —.Address - -. - <br /> - f <br /> Contractor <br /> ,,//�� )) �. Address License-No.' Phone <br /> aa__.Y51�f� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Weli ;:Cl <br /> CJ <br /> _ MoAitoz•ing Well <br /> '-� PUMP INSTALLATION_❑ Y _ SYSTEM REPAIR ❑ OTHER�Q <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, u <br /> C7 Industrial D Open Bottom r❑ Manteca Dia..ot Wall Excavation <br /> Dia. of Well Casing- <br /> CI Domestic/Private 0 Gravel Pack r D Tracy --R Type of Casing Specifications { <br /> { <br /> I'! Public [a Other ._n Type of-Grout <br /> depth of Grout Seal 3 <br /> i I Irrigation _.Approx. Depth x, l I Eastern Surface Seal Installed 4y <br /> Repair Work Done 0 Type of Pump H.R. State'Work Done <br /> Weil Destruction ❑ Well Diameter ; <br /> Sealing Material & Depth <br /> Depth_{ Z Filler Material & Depthy }y 6 3 <br /> p <br /> TYPE OF SEPTIC WORK: NEW iNSTAI LATION I l' REPAIRIADDITID ;DESTRUCTION I I lNo septic system perrrikied if publ "IllT. <br /> ilable within 200 feet`) H f <br /> installation will serve: Residence— Commerciaf- :a C4,, 1� 7 ° <br /> f Number of loving units: - Number of bedroom 4 }: <br /> Character of soil to a depth of 3 feet: 'Water table depth <br /> SEPTIC TANK V' Type/Mfg G Capacity No. Compartments d <br /> No. <br /> of Disposal <br /> PKG. TREATMENT PLT, El !. ,. _ �. t 1 ;ll ! <br /> Distance to ngarest:;� Well _ _ Foundationi Property Line - ! <br /> ) <br /> LEACHING LINE' ill"No. 8 Length of�lines.. a Total length/sire <br /> �r i <br /> FILTER BED CIDistance to nearest: Well - �-- Foundation Prop rty tine _ <br /> SEEPAGE PITS I I Depth Size_ i Number <br /> I SUMPS "' Cl Distance to nearest: Well Foundation Property Line ; <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application anb that,heiwork will be done in�ziccoidance with San!Jg4uin,pounty ordinances, Mata laws, and <br /> rules and regulations of the San Joaquin County <br /> M, Home owner or licensed agent's signature certifies the-fol "I certify that in the performance of the f ork fo whichtthis permit is'issued, I shall not <br /> I., employ any person in such manner as to become subject to workman's compensation laws of California." Contra �r's hAng or sub-contracting signature <br /> certifies the following: "I certify that in the performance of._the woSk for which this permit is issued, I shall im'Ale 4r5oripblect to workman's compensa- <br /> tion laws of California." .,J <br /> .The applicant must call for all required i spections. Complete drawing on reverse.side. <br /> ` Ji <br /> -Title bats: <br /> Signed <br /> Signed C9S <br /> ! FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> ..­" t <br /> Pit or Grout inspection by <br /> Date Final Inspection by Date 170 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County"Public Health <br /> Services, Environmental Health Permit/Services <br /> I 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> iCKV <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> + a EH 13-24{REV.tin 5) <br /> EH 4-211 <br />