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APPLICATION FOR PERMIT <br /> 4) <br /> SAN JOAQTJIN_.COUNTY PUBLIC HEALTH SERVICES � <br /> j` ENV I RONMENTA \HEALTH DIVISION <br /> 9i f 1.601 E. HAZEI,TON AVE- ,' PHONE (209)468-3420 <br /> li P 0 BOR 2009, STOCKTON, CA 95201 ` <br /> i� <br /> EXP RES 1 YE&R FR M DA E LlaILED <br /> (Complete in Triplicate) <br /> J <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 1.862 and the Rules and Regulations of San <br /> M <br /> Joaquin County Public Heal Services. <br /> City f>'ize/Acreage <br /> Job Address I � <br /> i a / <br /> Owner's Name <br /> Address Phone <br /> Contractor <br /> W� Address k License No r Phone <br /> TYPE OF WELL/PUMP: h1; NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ put M Service Well Cj <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> OTHER ❑ Monitoring Well ❑ <br /> i. SEWER LINES �-- DISPOSAL FLD. PROP, LINE <br /> DISTANCE f0 NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION �i4 iCU TL�1,RE-WELL``_\ 1 <br /> A"�'11VTEf3DE0"IJSE "— "'TYPE-OF-WEL'L PROBLEM?REA CONSTROCT ION'SPECIFIC-ATIONS- - <br /> IIDia. of Well Casing <br /> ndustrial C) Open Bottom O Manteca' Dia:of:,Well Excavation <br /> � Specifications <br /> I! 'Cl DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Easing- - LL <br /> fl Delta Depth ofGrout Seal i <br /> I'1 Public Type of Grout 1 <br /> C3 Other _ i I <br /> ii , <br /> �I ! Irrigation _.Approz`Depth 1 1 Eastern ace Seal Inslalted,tiy' <br /> {�" Type bf f ump. ' �� H.P. State Work Done <br /> e Repair Work.Done 1 >, Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter..,f i <br /> Depth I .art t Filler Material & Depth <br /> TYPE OF SEPTiC WORK: NEW IN�A LLATION l I REPAIR/ADDITION I I DESTRUCTION I I INO s pticavailathin 200 feet.)sy tem <br /> SY <br /> ed i <br /> Installation will serve: Reside�ncs - Commercial <br /> Number of living units: Number of bedrooms 1 t `^ Water table depth ) <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg ' Capacity No. Compartments , <br /> PKG. TREATMENT PLT. ❑ 1' Method of Disposal <br /> I+ Distance Io nearest: Well Foundation Property Line <br /> li F <br /> I � Total length/size <br /> r LEACHING LINE CI_No, & Length of,lines <br /> r Property Line <br /> FILTER BED C7 Dhistance to nearest: Well Foundation t71 <br /> I. SEEPAGE PITS 1!1 Depth Size Number <br /> SUMPS Ll Distance to nearest Well I Foundation' '_Property 4i <br /> �, <br /> DISPOSAL-PONDS ❑ <br /> I <br /> I hereby certify that I have'prepared this application and that the worl`_will-be-done-in-accordance-with-Sari Joaquin county ordinances, state laws, an <br /> rules and regulations of the-San Joaquin County <br /> Home owner or fit 's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall <br /> employ any per n in such r'na ar as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signan <br /> certifies the f awing: "I certif that in the pert rmance he work for which this permit is issued, I shall employ persons subject to workman's compentur <br /> sa- <br /> tion laws of alitornia." <br /> The applic. t mus c r requi d i rawmg on r =id1 � <br /> YA <br /> Signed X . <br /> Title: Date: <br /> I i F DEiaARTMENT USE ONLY <br /> Application Accepted by <br /> I' Data Area <br /> ` IDate Final Inspection by Date 7 <br /> q Pit or Grout Inspection by <br /> Additional!Comments: <br /> Applicant -- Return all copies to: San Joaquin County Public Health <br /> + Services, Environmental Health Permit/Services <br /> f 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> iii CK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH I <br /> �j pp <br /> . EH 13-24(REV.t/R5) <br /> I <br /> EH 14.26 <br /> - if <br />