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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)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 ' <br /> REMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to Sen 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 /> Job Address _ /�� J / o / t y City Lot Size/Acreage <br /> Owner's Name re <br /> —IS an�2yz Phone <br /> Contractor cess se No. Phony <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 14!' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom I-] Manteca Dia. of Well Excavation Dia. of Well Casing -` <br /> C.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'1 Public C1 Other 11 Delta ' Oept6 of Grout Seal Type of Grout <br /> I I lrrigation —..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material Depth _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION V1 DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feet.) r' <br /> Installation will serve: Residence_ Commercial__._._ Other <br /> Number of living units: ___L____ Number of bedrooms r M <br /> Character of soil to a depth of 3 feet: Water table depth ';r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �- <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Dunce to nearest: Well Foundation Property Lina <br /> �. <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line r'3 42 <br /> i t <br />` EEPAGE PIT I I Depth Number _ <br /> SUMPS Cl Distance to nearest: Well F Z20 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 subcontracting signature <br /> cartifies 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 /> II The applicant must cA24pr equir di pections. Cam to drawing on reverse side. <br /> Signedtl <br /> Title: - Dater ` r� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by Date Final Inspection by Date /4 9� <br /> F. Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Serviceal Environmental Health Permit/Services 1( <br /> .f <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK III CASH RECEIVED BY DATE PERMIT'N0. <br /> INFO I] p <br />