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rt APPLICATION FOR PERMIT �+ - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 N <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> �RR11IT EXPIRES YEAR R M D E ED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or insta.31the 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. k&/ <br /> r S F S le City Lot Size/Acreage (0 I <br /> Job Address <br /> C /� Phone <br /> Owner's Name Address <br /> Contractor <br /> �e.j Address License No. Phoria <br /> TYPE OF WELL/PUMP: NEW_WELL Q WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ <br /> OTHER D Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK j SEWER LINES DISPOSAL FLD.. PROP, LINE <br /> FOUNDATION + AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OFIWELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Cl Industrial 0 Open Bottom �Li Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> f:l Domestic/Private ❑ Gravel Pack L7 Tracy Yp g Tsps of Grout <br /> i"1 Public Cl Other n Delta Depth of Grout Seal <br /> I I Irrigation ^..ApproK. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H,P. State Work Done <br /> Sealing Material A Depth <br /> Well Destruction O Well Diameter Filler Material A Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INST-ALtAT40N-.I--REPAtR/ADDITION..i_I, DESTRUCTION INo septic system permitted i} public sewer is <br /> + available within 200 teat.l <br /> Installation will serve: Residence i Commercial J.._. Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to s depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg Capacity-_—__�_� No. Compartments -r <br /> PKG, TREATMENT PIT. C7 Method of Disposal � N <br /> , <br /> Distance to nearest: Well Foundation Property Line <br /> rr <br /> Total length/size <br /> LEACHING LINE 0 No. & Length of lines <br /> FILTER BED ❑ Distance.to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> to near`-nearest:"' Property Line <br /> SUMPS LI Distance [o Well Foundation <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 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 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 /> Theapplican_t4nust call for all required inspections, Complete.drawing on.reverse.side. <br /> Signed X <br /> Title: Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by y <br /> Date Area <br /> Pit or Grout Inspection by ; <br /> Date° Final Inspection by Date <br /> r <br /> Additional Comments: <br /> Applicant - Return all copies to: Pian Joaquin County Public Health r <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> FEE CK' RECEIVED BY DATE AERMIT N0. <br /> INFO f—A <br /> NT DUE AMOUNT REMITTED CASH (�t (� <br /> . EH 13.24taev.,�Ks1 t1� !( [ 1 ` <br /> + EH i4-26 <br />