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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 BOR 2009, STOCKTON, CA 95201 <br /> PFJMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> E° (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 /> Juin Count l�lth Services. S f f d <br /> A JobAddress t� c44gk,.,o Lot Size/Acreage Y6.11J a6- .. <br /> Owner's Name &1 31 .�LY��7ress Phone <br /> i <br /> Contractor - Address License No.,2S!C;?d Z Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER Cl Monitoring Well X <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE° .+9-.TG <br /> FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �d— 'r'°— Yp <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing (_ <br /> fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications w <br /> I[') Public I-1 Other Cl Delta Depth of Grout Seal _ _ Type of Grout r <br /> 1 # Irrigation I') Easter Surface-Seal Installed by ?� <br /> Repair Work Done U 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 I I {No septic system permitted if public sewer is <br /> available within 200 Ieet.I <br /> Installation will serve:' Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth I <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line .F+ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: " Wellm* Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI 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 taws, and <br /> rules and regulations of the San Joaquin County ` ' -4 i <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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The.applicant must call for all required inspections. Complete_drawing on reverse side, <br /> Signed X_ G/f�' Title: - - Date: <br /> j FOR E ONLY <br /> Application Accepted by Date re 3 <br /> Pit or Grout Inspection by Date Final Inspection b Date '/ <br /> Additional Comments: _C agel— C <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE I{l INFO AMOUNT DUE AMOUNT REMITTED CK 9 <br /> CASH RECEIVED BY DATE PERMI7'NO. <br /> t r//ti /,�7 <br /> + EH 13-24 IRMv i n s! (le Com/ �� v'fictl <br /> EH <br />