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APPLICATION FOR PERMIT , <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 _,p t ' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDN`'�7 P <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 <br /> QPublic Health Services. <br /> Job Address U City Lot Size/Acreage <br /> Owner's Name ,d t C[ Address Phone Y�4 44 <br /> r <br /> Contractor ��E"- Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - DESTRUCTION ❑ Out of Service Well ❑ { <br /> PUMP INSTALLATION Cl 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 Y_ <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> U industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [❑ Domestic/Private ❑ Gravel Pack L] Tracy Type of Casing Specifications ; <br /> FI Public El Other f1 Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation Approx. Depth I I Eastern Surface Sedl Installed by t <br /> Repair Work Done C Type of Pump H.P. � � _State Work Done <br /> Well Destruction ❑ Well Diameter=- """Sealing Material & Depth p� M <br /> Depth �! Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I; REPAIR/ADDITION I I_ DESTRUCTION INo septic system permitted if public sewer is <br /> ✓� t a . S�, . t available within 200 feet.) <br /> installation will serve: Residence Y Commercial" Other <br /> Number of living units: Number ofbedrooms r <br /> Character of soil to a depth of 3 feet: i '`-' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity * ` No. Compartments <br /> PKG. TREATMENT PLT, ❑ F Method of Disposal <br /> Distance to`nearest: -Well Foundation Property Line } �` <br /> LEACHING LINE Cl No. & Length"ot,lines J Total length/size ? + <br />(LV FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number I <br /> SUMPS it Distance to nearest: Well Foundation Property Line f <br /> DISPOSAL PONOS ❑ <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 ficensed agent's signature certifies the following: "l 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 /> The applican�call equired ins coon Complet draw) ese side.Signed 7� �� Title: Date: <br /> / FOR DEPARTMENT USE <br /> ONLY <br /> Z <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date �L 3 <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 /> CK I <br /> FEE INFO AMOUNT DUs: AMOUNT REMITTED Cr�ASH RE/CEIVED By /J D/A]T�E /PJERMIT'NO` ; <br /> . EH c3-2�IREV.tlKsl LJ[7 J Gd I/�� G "�i 1 `r- %(� `��/ <br /> EH 34-2a lj rC <br />