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APPLICATION FOR PERMIT <br /> I <br /> F <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCETON, CA 95201 <br /> RFRMIT EXPIRES 1 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. f <br /> Job Address S City Lot Size/Acreage / „ <br /> Owner's Name Address ! � Phone ' / <br /> ContractorAddressomi__ _- License No. ` ! bhone <br /> TYPE OF WELL PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION O S STEM REPAIR Ll� OTHER D Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES j DISPOSAL-FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE ELL I OTHER WELL -,PITS/SUMPS <br /> • :INTENDED USE TYPE OF WELL PROBLEM AREA CO T CTlON SPECIFICATIONS <br /> C] Industrial --�- ❑ Open Bottom ❑ Manteca Di f Well Excavation Dia. of Wel! Casing + <br /> a DomesticlPrivate � Cl Gravel`Pack ❑ Tracy ype of Casing Specifications <br /> f'1 P iblic 1-1 Other (i Delta Dept of Grout Seal .Type of Grout ' <br /> I I Irrigation —Approx. Depth I I Eastern Surf a Seal Installed by "y <br /> Repair Work Done ❑ r Type of Pump H.P. ` State Work Done-. <br /> Well Destruction a O a Well Diameter Sealing"Material &yDepth ti i <br /> Depth �01Filler Material &`'-Aepth <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION `REPAIR/ADDITION I I PEST CTIONI (No septic system permitted it public sewer is W <br /> " av b with' '200 le r.i <br /> .. <br /> Installation will serve: Residence Commercial Other f <br /> Number of living units: Number-of bedrooms�T <br /> -5.. rye ��,.l <br /> Character of soil to a depth o/3 feet: � Waabla dept <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No:Compartments <br /> PKG. TREATMENT PLT. Cl �A tr _� Method Dispo I <br /> ! Distance to nearest: Wel! V Foundation r6perty Line-4110 <br /> LEACHING LINE CI No. & Length of lines Tojal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation_Z ,Praperty Line <br /> x <br /> SEEPAGE PITS - .1 i Depth Sire N 1.umbef t. f7,42 ? <br /> SUMPS L3 Distance to nearest: Well Foundation Mil Property Line <br /> F DISPOSAL PONDS ❑ + <br /> 1 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 v s % , ; ; � ,.i <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 signatut <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 /> t The app cant t ll ar rauired ipeerions. Complete drawing on reverse Sde. (M.,mcaL` � <br /> Signed Title: r t Data: <br /> FO NT USE ONLY ry <br /> I Application Accepted by Date <br /> t 9 F <br /> TJ Area ! <br /> t <br /> Pit or Grout Inspection b Date Ficial Inspe ion by Date t3 !) t <br /> Additional Comments: 4_ El� <br /> Applicant - Return all, copies to: Joaquin County Public Health E { <br /> Services Environmental.health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE `s r <br /> INFO AMOUNT DUE AMOMT REMITTED CK V <br /> CASH RECEIVED BY DATE PERMIT'NO. r <br /> . EH A-24(A EV.1in51 <br /> EH2429 "T t Q� r�Gja� _ 370 <br /> 111 fC� [ <br />