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APPLICATION FOR PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTONI AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> phMIT RF YT <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 y <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 /> City�C��� Lot size/Acreage�� <br /> Job Address 67) <br /> Address ? Phone I <br /> Owner's Name _ t <br /> ContractorA6���_WL <br /> _Address f License [Vo Phone <br /> TYPE OF WL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of,Se ice Well ❑ <br /> OTHER G Monitoring Well <br /> iPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ , <br /> SEWER L{N!E �--.-_ '''DISPOSAL FLD. PROP. UNE <br /> DISTANCE TO NEAREST: SEPTIC TANK .� <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL" PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, i <br /> f n Bottom is Manteca Dia of Well Excavation Dia. of Well Casing <br /> n Industrisl ❑ Open / c I !' j I <br /> } r; 10 Gravel Pack C7 Tracyi T`ygii`ot;.Casing Specifications <br /> Domestic/Private r <br /> j ;'1 Public ;Cl Other n Delta; Depth'of`Grout Seat Type of Grout' <br /> ! _ Approx. Depth 1 I Eastern SuAace Seal'tnseaued`by <br /> r Ini{lation — <br /> H p. ' State Work Done,_ i ! <br /> Repair Work Done U Type of Pump Sealing Material i Depth <br /> Well Destruction O V1fe�1 Diameter _�.- l + I <br /> Depth ; Filler Material 6 Deptb <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No sepiic,system permitted it,public sewer is <br /> available within 200 feet-I } <br /> installation will serye: Residence Commercial � Other <br /> Number of living units: <br /> Number of bedrooms ! <br /> Character of soil to a depth of 3 feet: <br /> Water tabic depth <br /> � .L — Capacity No. Compartments <br /> SEPTIC TANK O Typelmfg. --- - I <br /> r• �- Method,of Disposal <br /> PKG. TREATMENT PLT.O � ' <br /> t , Foundaiion iroperty Line '�z I , <br /> .r --•- Distance to nearest:, ; '•Well <br /> No. & Lan Length of lines Total length/size_ <br /> LEACH NG LINE ! g - - J <br /> -- FILTER-BED <br /> ` r) Distance to nearest: Weil Foundation Property Lines` —. I <br /> r r { <br /> �.. _ <br /> SEEPAGE PITS <br /> If Depth —Size �~Numbler r <br /> SUMPS Cl Distance to nearest: Well / FoundatioA ' "�`" Property Line <br /> DISPOSAL PONDS D. <br /> prSpanad iFis aPPlication and that the work will be done in accordance vYith San JoaQuiri'county ordinances, state Taws, and <br /> I hereby certify that I have <br /> rules and regulations of the San Joaquin Countyi <br /> Home owner or.licensed agent's signature certifies the following: "1 certify that in the performance of the Work for which this permit rs issued, 3 shall not <br /> employ any person in.sikh manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-&Nracting signature <br /> certifies the followiri: "I certify that in the performance of the work lor which thispernNt is issued,I shall employ parsons subject to workman's compensa <br /> tion laws of California.' l ' <br /> The applicant must call for'al squired sped Complete drawing on revere skis. .t ' <br /> Tale: I Date- <br /> its. r Signed X <br /> FOR pEPARTMENT'USE ONLY C� � , <br /> '• Datq Area � <br /> " Application Accepted by <br /> �v <br /> }' I � � <br /> Fidel—Inapattion bp�—'rn <br /> Pit or Grout Inspection by ' Date, - i <br /> Additional Commsnti:. I <br /> Applicant - Aeturn all°copies to: San Joaquin County PublicrHealth 1 <br /> I Services, ftvironmental Health Permit/Services <br /> } + 1601 E. Hazelton Ave., P.0 Box 2009. Stockt , CA 95201 4 <br /> on <br /> !,ti FEE AMOUNT DUE AMOUNT REMITTED SK RECEIVED'9Y DATE PERMIT'NO.. <br /> :. �I FO ( _ - CASH - <br /> r. jli�1 <br /> 1 o O <br /> tIIN 14416 t <br />