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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 /> EXPIRES 1 YEAR FROM DATE ID <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> ' -Z City `'� -" Lot Size/Acreage <br /> Address Phone <br /> Owner's Name <br /> Contractor <br /> J Address �! c License No ���� Phone <br /> TYPE OF W L/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHER ❑ <br /> Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> .n Industrial Cl Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public f-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx..Depth 1 I Eastern- Surface Seal Installed by <br /> Repair Work Done CJ 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 REPAfR/ADDITION I ! DESTRUCTIONV fNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Numbe*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 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING-LIN.E Cl No. & Length of lines Total length/size A <br /> f FILTER BED Cl Distance to'nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number a <br /> !I SUMPS 0 Distance to nearest: Well Foundation Property Line �} <br /> y DISPOSAL PONDS O <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 s{bject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the pertormahce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califor jj <br /> The applicant rYiust 1E it d in pections. Complete drawing on reverse side. <br /> q Signed <br /> ti Title: Date: <br /> FOR DEPARTMENT USE ONLY ` <br /> `1Date 0 Area <br /> Application Accepted by L� <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant- Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Realth Permit/Services <br /> 1601 E. Ra.zeltoo Ave., P O,Box 2009, Stockton, CA 95201 <br /> EEEAMOUNT DUE AMOUNT REMITTED CKS RECEIVED BY DATE PERM17 N0. <br /> INFOt _3 �f ��,, <br /> a £H 17.24 IREV.I/"W <br /> V 190 <br /> E H A-2e <br />