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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> P3sRMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I <br /> Application is hereby made,to San Joaquin County far 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 i <br /> Joaquin County Public Health Services. 1 <br /> Job Address City Lot Size/Acreage <br /> i <br /> Owner's Name Aw Address v Phone 0O ]] <br /> Contractor M-6 Address S Address License No. Phone i <br /> TYPE OF WELL/PUMP: NtW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTIONA Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 11 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 i <br /> ❑ Industrial ❑ Open Bottom I-] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i <br /> f'] Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I I laigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of PumpH.P. State W�rk Don _ <br /> Well Destruction Well Diameter' ^ Sealing Material & Depth v <br /> ,X10 <br /> Depth Filler Material & Depth 7 /. <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION R I REPAIR/ADDITION'l I DESTRUCTION I l INo septic system permitted if public sewer is l <br /> available within 200 feet.) <br /> Installation will serve; Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK .. 0 Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundations Property line 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 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 /> The applicant It rwire omplete drawing on reverses d~- <br /> Signed X tle: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b Date Area C <br /> Pit or Grout Inspection y Date Final Inspection by Date�D <br /> Additional Comments: w ra e 3 o CtPtd <br /> Applicant - Return all copies to: San Joaquin County-Public-Health Y. N, ' <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> EEE " AMOUNT OUE AMOUNT"REMITTED CK RECEIVER-8Y\ DATE PERMIT'NO. <br /> INFO CASH. <br /> a EH 13-24(REV.iInsl fZ <br /> EH 3•-26 S <br />