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APPLICATION FOR PEMIT <br /> Eh s IF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION *if <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 <br /> 4�k / <br /> PFMIT EXPIRES ]. YEAR FROM DATE ISSUED <br /> (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 /> Joaquin County Public Health Services. - ATA P I U M - <br /> Job Address -;P,3 City Lot Size/Acreage <br /> Owner's Name g Address �e 349 /�/a'��� --A :. Phone L�® 96 <br /> Contractor le Address_ Zr,& J License No.V —0 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ R <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP L FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ER WELL PITS/SUMPS "V <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS <br /> f7 Industrial ❑ Open Bottom ❑ Manteca �iaell Excavation Dia. of Well Casing <br /> [I Domestic/Private Cl Gravel Pack ❑ Tracyasing SpecificationsI') Public Ci Other I1 Delta .- .� Depth of Grout Seal Type of Grout , <br /> i I Irrigation .Approx. Depth I I E m Surface Seal Installed by <br /> Repair Work Done- U Type of Pump H.P. State Work Oone <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth { <br /> Depth �: Filler Material & Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONf h;REPAIR/ADDITION I I DESTRUCTION INo septic system permitted it public sewer is ; <br /> v available within 200 feet. <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: t Water table depth <br /> SEPTIC TANK Q 9Type/Mfg Capacity No. Compartments j <br /> PKG. TREATMENT PLT.❑ ) ,- _ _! Method of Disposal <br /> Distance to nearest: Well' Foundation f Property Line <br /> LEACHING LINE �❑ No. & Length of lines ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation - I Property Line <br /> T +� . <br /> SEEPAGE PITS 11 Depth Sizef --"-' -Number <br /> SUMPS Ul 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 laws, and <br /> rules and regulations of the San Joaquin County i <br /> Home owner or licensed agent's signature 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 ust call for all re it ins ' n s. Cbmplete drawing reverse sl 01 <br /> OL <br /> y 4 '� , 4 a t•� r V. <br /> Signed 6 Title: Date: <br /> ENT USE ONLY <br /> Application Accepted by ' Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date C <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 <br /> INFO —yAMOUNT DUE AMOUNT REMITTED �K H RECEIVED BY DATE PERMIT'NO..?- <br /> + EH 13-2a IREy.t/n sr 5 9 <br /> EH;4-2e ✓ vim✓T <br />