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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a <br /> ! ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> REMIT EXP RES „I YEAR FRAM 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 /> ad <br /> application is me in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> `Joaquin County Public Health Ser ices.. <br /> i� fob Address CitvS— -AI Lot Size/Acreage .Sbya b <br /> T <br /> Owner's Name Q- Address Phone <br /> # P <br /> Contractor t Address is nee No. �Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ Monitoring Well ❑ <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Fl Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications <br /> I.1 Public D Other n Delta`' Depth of Grout:Seal i Type of Grout <br /> f I Irrigation <br /> Approx..Depth I I Eastern Surface Seal Installed by <br /> I <br /> Repair Work Done Ll Type of Pump, j H.P. t State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth 1 Filler Material &Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION.I,..I„_DEST._RUCTION 1 fNo septic system permitted if public sewer is <br /> r available within 200 feet,I <br /> Installation will serve: Residence_ Commercial i Other i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: } ' f Water table depth <br /> SEPTIC TANK ❑ Type/Mfg # Capacity' No. Compartments <br /> PKG. TREATMENT PLT. ❑ i � "% iMethod of Disposal <br /> Distance to nearest: W60 Foundation r Property Line <br /> LEACHING LINE Cl No. & Length of lines E Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> } <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI 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 <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 /> I <br /> The applicant must call for all required i pections. Complete drawing on reverse side. ff! <br /> Signa Title: Date: y!.� <br /> I <br /> EPARTMENT USE ONLY <br /> fI <br /> Application Accepted by C.. ,�,,` , �r_��y„ Date '1 S-29 0 Area <br /> Pit or Grout Inspection by Date Finan Inspection by Date _mg zS r o <br /> Additional Comments: <br /> .. <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 GK <br /> INFO b CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 3.24 1 <br /> + FH7�.26IREV.iixs! ..LJV ' 36,00 <br /> i <br />