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' APPLICATION FOR PERMIT <br /> j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT 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. <br /> r ' <br /> Job Address City Lot Size/Acreage <br /> Owner's Name r"� Address i-_-� , y / Phone <br /> /ddress /d U_ License iVo. S Phone' <br /> Contractor — <br /> TYP.E.OF..WELL/PUMP: NEW WELL El 4 WELL' EPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> �' +SY TEM REPAIR C7 OTHER ❑ Monitoring Well <br /> UMP INSTALLATION ❑ L ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 4 FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS <br /> l INTENDED USE: TYPE OF WELL PROBLEM AREA '� NSTAUCTION SPECIFICATIONS ` <br /> r ...F.1-Industrial CJ Open Bottom = ❑ Manteca €a. of Well Excavation Dia. of Well Casing <br /> t 11 Domestic/Private ❑ Gravel Pack CJ Tracy . , ype of Casing Specifications <br /> !'1 Public i.1 Other (71'Delta r Depth of Grout Seal Type of Grout <br /> I Irrigation . - -• _-�•- �.Approx. Depth l I East �JSurface Seal Installed by n <br /> 1'RepaiFWork Done kLl Type of Pump s H.P, —; State.Work Done <br /> L Wall Destruction.,,._0 Well Diameter Seal !¢aterial & Depth <br /> r i <br /> Depth Filler Mat rials &.Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATON REPAIR/ADDITION 1 1 ;DESTRUCTION-I-'I (No septic system permitted if public sewar is 3 f� <br /> r available it feet V <br /> Installation will serve: Residence Commercial ; Other " -- - fi <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 4 _ _ I Water table depth <br /> I SEPTIC TANK ❑ Type/Mfg 'G ~Capacity— No. Compartments <br /> r t PKG. TREATMENT PLT. 0 € � ' � t y Method f Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ? LEACHING LINE Ll No. & Length of lines 2_ - To I length/size ` <br /> FILTER BED ❑ Distance to nearest. Well 1 foundation Property..Lins - <br /> t � � y Y a <br /> SEEPAGE PITSA <br /> I.!I Depth Size t--�- Nu ber <br /> SUMPS Ll Distance to ne est: Well oundation Property Line r <br /> DI POSAL PONDS C!_) .� I ___ UUU <br /> K `fes <br /> I hereby certify that I have prepared4his application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> # ruled and regulations of the San Joaquin-County <br /> € I Home owner or licensed agent's signature certifies the following: "I certify ltl tk 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- il' <br /> € tion laws of California." ^..i <br /> I E` The applicant m t call fora quired i pections. Complete drawing on reverse side. ._ <br /> € c � � `-Ill<fJ <br /> Signed *Title: Date: <br /> r T1kN7'f1S7c ONLY <br /> Application Accepted by - Date Area <br /> 1 Pit or Grout Inspection by Date Final Inspection by_ -- Date <br /> I t f'' , <br /> Additional Comments: '` <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> e 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> k INFO CASH <br /> EH -25(REV. /nS) `�� 44 �j� ! u b rib "�D3 <br /> -75A <br /> EH i�-2B iii <br />