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APPLICA.'I�.I.L?�OR PERMIT <br /> M <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' ENVIRONMENTAL HEALTH DIVISION ""ECEIVEU <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> SEP 6 p O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL <br /> ENTAL HEALTH <br /> bttiRluIT EXPIRES 1 YE R FROM D LA PERMIT/S@RVICCS <br /> (Complete in Triplicate) <br /> Application is hereby made to Sam 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. 1 ` <br /> `� City J} Lot Size/Acreage <br /> Job Address 9 <br /> �y .ss D _— Phone <br /> Owner's ress <br /> a �� <br /> i nse No.T� Phone <br /> n r Clor ss <br /> WELL REPLACE ENT n DESTRUCTION ❑ Out of Service Weil 0 <br /> TYPE OF WELL/PUMP: NEW WELL Cl OTHER ❑ Monitoring Well E7 <br /> !. `PUMP INSTALLATION ❑ SYSTEM REPAIR C] <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES – DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT5ISUMPS <br /> f <br /> INTENDED USE,,,"- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> l7 Domestic/Private Gravel Pack racy <br /> Type of Grout <br /> �SZ'Pr <br /> ' blit ~`I:1 Other n Deita Depth of Grout Seal <br /> gation ,_..�.App(ax. Dep h l I astern Surface Seat Installed by r <br /> I of Pump H.P. State Work Done <br /> Work Done <br /> Type �y� Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter a Material & Depth <br /> DepthjftLLe <br /> TYPE OF SEPTIC WORK: NEW iNST.ALLATION_I_1, REPAIRlADDITION l I DESTRUCTION I I afvailabe within 200 feeto septic syslem .) if public sewer is <br /> Installation will serve:_ Residence.— Commerciil— Other <br /> Number of living units: Number of-...bedrooms r Water table depth <br /> Character of soil to a depth of 3 feet: ' / No. Compartments <br /> SEPTIC TANK Cl Type/Mfg t- Capacity <br /> � <br /> PKG. TREATMENT PLT.❑ 3 Method of Disposal <br /> Property Line <br /> Distance to nearest: Well Foundation <br /> LEACHING LINE ❑ No. & Lenges Total length/size sof lines A <br /> FILTER BED n Distan e o nearest: Well Foundation Property Line <br /> Size <br /> SEEPAGE PITS I 1 Depth Number <br /> i SUMPS Ul�Distance to nearest: <br /> well Foundation Property Line <br /> M 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: "1 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." Contracto�nhirin ectt tobw ontrac ing sig ensr <br /> certifies the following:'I certify that in the performance of the work for which this permit is issued, l shall employ p__ __.___1.__ <br /> tion laws of California.,- """`"'"1'"'—� J <br /> The apptics st call f t al ired inspections. Complete drawing on rev sid <br /> Sig d <br /> Title: Data: <br /> FOR DEPARTMENT USE ONLY/ <br /> i – Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date �3 <br /> Additional Comments: <br /> Applicant – Return all copies to: Servi�ulnCounty Environmental itHealthPermit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> F EINFO <br /> CK RECEIVED BY 0 TE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> EH 13.24 1REV.+ K 51 �5 " <br /> EH 1428 <br />