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�tvv <br /> APPLICATION FOR PERMIT r <br /> " t+i <br /> SAN JOAQUIN COf;TNTY. PIIBLIC HEALTH SERVICES <br /> ENVIRONMENTAL .HEALTH DIVISION <br /> 1601 E. RAZHLTON AVE. , PHONE (209)468 <br /> E COPY <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> RES 1 YEAR FROM DAT ED <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 Se ies. t <br /> t City t Size/AtPhone <br /> Job Address .Q <br /> Owner's Name Address <br /> Contractor rens <br /> License Na. one <br /> TYPE OF WELLIPUMP: NEW WELL ❑— / WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Monitoring Well ❑ <br /> PUMP INSTALLATION fly SYSTEM REPAIR ❑ OTHER ❑ <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 /> C7 industrial ❑ Open Bottom ❑ Manteca <br /> Dia, of Well Excavation Dia.of Well Casing <br /> Type of Casing-- <br /> _I Specifications <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy 9 i <br /> I1 Public (-IOther i"1 Delta Depth of Grout Sea{ Type of Grout <br /> Isf'lrrigarion _ Approx. Depth I i Eastern Suiface-Soul Installed by \ <br /> Repair Work Done Ll Type of Pump H. t State Work Done <br /> � <br /> sealing Material;& Depth QJ <br /> Wall Destruction ❑ Well Diameter <br /> Depth Filler Material 8 Depth <br /> i <br /> ' TYPE Of SEPTIC WORK: NEW INSTALLATION I 1 REPAIRJADDITI N I--I- IFSTRUCTION I I INo septic system permitted it public sewer is ➢J <br /> " available within 200 feet.! <br /> Installation will serve: Residence— Commercial Other•, 1 <br /> Number of living units: Number of bedrooms <br /> i <br /> Character of soll to a depth of 3 feet: - i � ' ,.. - Water table depth L ', <br /> ..._ <br /> SEPTIC TANK ❑ Type/Mfg s ' rC6pacity � No. Compartments ; w <br /> PKG. TREATMENT PLT. ❑ `-i Method of Disposal <br /> Distance to nearest: Well Foundation/ �` Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Prboerty Line f <br /> DISPOSAL PONDS ❑ 3i ' <br /> I hereby certify that I have prepared this application and that the work will be done in`ac Zidahcetwith San Joaquin county ordinances, state laws, and�� <br /> rules and regulations of the San Joaquin County c' <br /> Home owner or tic ent's signagg, he following: "I certify that in the performance of the work for which this permit is issued, 1 shall notampioyanyper n in suc manner a bject to workman's compensation laws of California. ContractoPshFring or subcontracting signature <br /> certifies Lha fa wing: "1 rtit thaante of the work for which this permit is issued, I shall employparsons subjeot ta.workman's compensation laws of aiifornia." <br /> The applic t s for I r omplete drawing o se $i / D <br /> Signed Title: Date: <br /> t <br /> FOR PARTMENT USE ONLY <br /> Application Accepted byDate r I Area <br /> _A" <br /> Pit or Grout Inspection by Date rt Final Inspection by Data <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 MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE MIT NO. <br /> INF . <br /> r EH 13-24 1REV.L i a 5) -2Z �k,_ <br /> EH14.28 <br />