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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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Bo. 549 and 1862 and the Rules and Regulations of San <br /> Joequin County Public Health Services. '[`_ <br /> Job Address ""'� e�—�'—ciity� 01 <br /> Lot Size/Acreage ���--- <br /> Owner's Name ti' s+^-- Addd'ress <br /> ress �^'r"� Phone <br /> ' <br /> Contractor � ¢ JP Address , ` t2 £ License No. 7[`f 170 / _rPhone <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 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of WeII Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ s <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth / <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION- DESTRUCTION I I (No septic system permitted it public sewer is <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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linesQ T�otal length/size <br /> FILTER BED 1-1Distanceto nearest: Well P Foundation-A — Property Line e <br /> SEEPAGE PITS 11 Depth J <br /> Size _ Number <br /> SUMPS LI Distance to nearest: Well t`A92 ,� Foundation��,�_ Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby comity 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 must el or II req ins in Complete drawing on reverse side. <br /> Signed Title: (�� ! i- Date: S 12 <br /> J- FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date-_� Area /(^b <br /> r Grout Inspection by Date /7- /Final Inspection by star <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., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE ))AMOUNT REMITTED CASH ){RECEIVED BY DATEE� PERMIT NO. <br /> . EH 1 v3-24[REV. K 5 t"' ��' t7: L['. J� rrY ! -. l•' ,.. Iw'f:• .C��f�i-�.j"'- <br /> EN .26 .:4� 4✓ <br />