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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 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 -YEAR FROM DATE ED <br /> (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This j <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 3.862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name /�/ /I) ddress 1 1 Phone <br /> � I <br /> .;.(Contract Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C_ DESTRUCTION ❑ Out of Ser tee Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �OTER ❑ M oring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D PROP. LINE ' <br /> FO AGRICULT OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL EM AREA _ CTION SPECIFICATIONS <br /> 1 <br /> n Industrial CIO ttorn 0 Manteca •Dia. of Well Excava 1 Dia_ of Well Casing <br /> F <br /> ❑ Domestic!Industrial: <br /> ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications <br /> f'] Pu 1-1 Other l� Delta Depth of Grout Seat Grout <br /> I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material.& Depth <br /> s Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 7 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: _.L Number of bedrooms , ' <br /> Character of soil to a depth of 3 feet: <br /> fiWater table depth <br /> SEPTIC TANK. 111 <br /> O Type/Mfg Capacity - No. Compartments d <br /> PKG. TREATMENT PLf. ❑ ` Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size N l: <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS IJ Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 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, t 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 pertormance 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 ' specti*6 . Complete drawing on reverse side. <br /> r �� `, 10 <br /> Signed X Title: _ Date: 1�l�"` <br /> / <br /> 71 <br /> F EPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 7 <br /> Additional Comments: <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 AMOUNT DUE AMOUNT REMITTED CK 9 <br /> PERMIT NO.RECEIVED BY DATE <br /> INFO !Y` /CASH t(�{} <br /> iEH 13-24 rRfV.I N51 7 <br /> EH 11.26 C.� }.� ---I,I,Q 6,1 q <br />