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I <br /> a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION D <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 o <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR . M DA E ISPUED <br />'I (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 /> f` application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> /Services. / !n <br /> iJob Address City Lot Size/Acreage <br /> Owner's Name I !�/ Address A111!�4_ Phone <br /> Contractor eG — Address License No. Phone <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 PROBL'EMAREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> C:7 Domestic/Private ❑ Gravel Pack C] Tracy Type of Casingi <br /> Specifications l <br /> I'I Public 1:7 Other n Delta Depth of Grout Seal <br /> i ! Irri ution —' - - p= Type of Grout <br /> E)' —Approx. Depth _I I Eastern ; Surface Seal 'Inst ailed by <br /> Repai-rWork-Done LJ Type of Pump, i H.P- State Work Done — <br /> Well Destruction p ❑ Well Diameter f sealing Material & Depth <br /> ��,Depth ° —Piller Material &_pbpth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I',1 DESTRUCTION (No septic system permitted if public sewer is f f� <br /> available within 200 feet.) t t <br /> Installation will serve: Residence Commerciil�= Other t-� _ <br /> Number of living units: Number of bedrooms <br /> i <br /> Character of soil to a depth of 3 feet: ? Water table depth <br /> SEPTIC TANK. ❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.'❑ € Method of Dispo-sal <br /> ".Distance to nearest: Well_ Foundation <br /> ' i Property Line <br /> LEACHING LINE ❑ No..& Lengttt.of lines Total lengthlsize <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 i Depth Size <br /> Numbs?• <br /> SUMPS LI -Distance-to-nearest:~—Well — <br /> DISPOSAL PONDS ❑ --Foundation- --- --Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> rules and regulations of the San Joaquin County state laws, and <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 i h manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies tfto followi : 'I certity that in the performance of the work for which this permit is issued, I shall employ persons subject to work man's,compensa- <br /> tion laws of Calif rnl .' <br /> The applicant u call for al a ired speetions. Complete drawing on reverse side. <br /> Signed <br /> Title: � f-- <br /> pats: � <br /> fl TMENT USE ONLY <br /> Application Accepted by t <br /> Date Area <br /> Pit or Grout Inspection by i' <br /> Date <br /> Additional Comments: Final Inspection by �! <br /> I _ Date <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 t <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO �e�� Cf KI[� RECEIVED BY 1PACT;EP� P, M,; <br /> � <br /> . Ek14-21IRSV.rinSi 5�.V� 3� ,r�V �LA J �^j [ —TV 0``f <br /> EH 71.26 <br /> I' <br />