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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 O BOX 2009, STOCKTON, CA 95201 <br /> PRIMIT <br /> EXPIRES 1 YEAR FROM DATE ISSUM <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 1$62 and the Rules and Regulations of San i <br /> Joaquin County Public Health Services. <br /> Job Address f Cit Lot Size/Acreage <br /> r <br /> Owner's NameAddresrss Phone <br /> Contractor Address J �� License No. 1�1D�fJr PhorwxO�f7 <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [7 <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 t CONSTRUCTION SPECIFICATIONS r <br /> * Industrial CJ Open Bottom ❑ Manteca Dia. of Well-Excavalion Dia. of Well Casing r <br /> * Domestic lPrivaie ❑ Gravel Pack L1 Tracy Type of.Casing Specifications 1 <br /> Il Public I.7 Other <br /> i fl Delta � Depth of Grout Seal � � Type of Grout 1 <br /> 1 I"Irrigation —.Approx. Depth I I Eastern Surface Seat Installed by 1 t <br /> 'Repair � Work Done"— <br /> llDeso Destruction ❑ Well Diameter _ Sealing Materia.-i-&-Depth- <br /> Wail State <br /> x Depth "` � F111er -Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION 1No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence V 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. Cj Type/Mfg Capacity .l�dC7 No. Compartments �- <br /> PKG. TREATMENT PLT. ❑ O / Method of Disposal tiLd <br /> Distance to nearest: Well Foundation 07Z9 Property Line {.4 <br /> :'; <br /> LEACHING LINE ❑ No. & Length of lines Total length/size..- /,, <br /> FILTER BED 0 Distance to nearest: Well- Foundation s Property Line_ <br /> SEEPAI E PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Wet] Foundation 1e4Property Line <br /> DISPOSAL PONDS CI iJ <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 mu all for all reed in pections. Complete drawing on reverse side. <br /> Signed X Title: 49&4 lLe=-_ Date: <br /> FOR DEPARTMENT USE ONLY / 1? !� <br /> Application Accepted by Date_ Area <br /> � � /� <br /> Z. <br /> or Grout Inspection by � 7 �+ Date� Final In=aa._Av/ <br /> Date.;�qq <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., F 0 Box 2009, Stockton, CA 95201 <br /> IF <br /> 0 MO NT DUE NT REMITTED CASH. RECEIVED BY DATE PERMIT'N0. <br /> EH17.24 1REY. - <br /> EH 14.2E c� �� �zf 3-12-� <br /> yf' �r-: <br />