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APPLICATION FOR PERMIT <br /> SAN JOAGZUIIV COUNTY PUBLIC HEALTH SERVICES <br /> ~ ENV I RONMRNTAL 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 ISSU <br /> (Complete in Triplicate) <br /> Application is hereby made.to Salt Joaquin County for a permit to construct and/or install the worst 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. A <br /> C1ty G Lot Size/Acreage <br /> 1 1 Job Address <br /> Y d �/Y( S Address Phone <br /> Owner's Name <br /> a 9 <br /> 7—License No. Phone <br /> Contractor (1 Address ��r ! �� <br /> TYPE OF WELL/PUMP: NEW WELL El ELL REPLACEMENT D DESTRUCTION ❑ Out Mo Service Well C1 <br /> O <br /> SYSTEM REPAIR ❑ OTHER D Monitoring Well C] <br /> PUMP INSTALLATION <br /> F. 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 <br /> F, L7 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br />' I"I Public 1,7 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approxi Depth I I Eastern Surface Seal Instal!ed by <br /> ' Repair Work Done IJ Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> F Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW IN I I-. REPAIR/ADDITION�(1 DESTRUCTIpN4 I INo septic system permitted if public sewer is <br /> / available within 200 feet) <br /> Installation will serye: Residence v Commercial_ Other <br /> Number of living units: --t— Number of bedrooms :9 — <br /> Character of soil to a depth of 3 feet: � 4= Water'tabie depth <br /> SEPTIC TANK © Type/Mfg Capaci#y;, Off] - No, Compartments <br /> PKG. TREATMENT PLT. 0 41f – Method of Disposal <br /> Distance to nearest: Well: Foundation �1..,r Property Liner F~ <br /> LEACHING LINE 9 No. & Length of lines � Total length/size ,2 �T <br /> l FILTER BED ❑ Distance to nearest: Well/,'a– _1'.' �Foundation 5 Property Line; X�--i F7- <br /> �F .t <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS , LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ci <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 04 sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this pe <br /> ficin <br /> issued, !shall employ Persons subject to workman's compensa- <br /> t: tion laws of California." <br /> The applicant must call for all equired inspections. Complete drawing on reverse side. <br /> ' Signed X�. Title: Date: S <br /> I FQR DEPARTMENT USE ONLY pp <br /> ' Area <br /> �' <br /> Application Accepted by Date _ <br /> Pit or Grout Inspection by Date Final Inspection by _e__ Data g� <br /> Additional Comments: <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> l 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> + FEE AMOUNT DUF. AMOUNT P,EM177E0 CK 9 RECEIVED BY DATE PERMIT NO. <br /> INFO CASH N <br />