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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> y ENVIRONMENTAL HEALTH DIVISION <br /> may. 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ft> <br /> IP O BOX 2009, STOCKTON, CA 95201 <br /> gYTT Z2ZIRES 1 YEAR FROM DATE ISSUED <br /> ! <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 compliancerwith Sass Joaquin county Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i t / �(i�-off City <br /> � Lot Size/Acreage <br /> Job Address — <br /> lI <br /> ! <br /> Address Phone <br /> Owner's Name C r! f! <br /> / r �((`� License No S �y Phone <br /> Contracto :A�dddress ' ._ <br /> TYPE OF W L/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Weli ❑ <br /> Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> 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 /> L3 Industrial 0 Open Bottom ❑ Manteca Die. of Well Excavation <br /> Dia. of Well Casing <br /> C) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ► I'1 Pribtic I-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irritation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material 1: Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic shin m permitted if public sewer is <br /> Installation will serve: Residence—" <br /> Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:;I Water table depth <br /> SEPTIC TANK O Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl J Method of Disposal <br /> Distance tol nearest: Well Foundation Property Line <br /> .1 <br /> LEACHING LINE Cl No. & Leneth of lines Total length/size Q <br /> FILTER BED ❑ Distance t8'nearest. Well Foundation Property Line 7 <br /> SEEPAGE PITS 11Depth �I Sue _ Number O <br /> SUMPS LI Distance'snearest: WeilFoundation_ Property Line <br /> DISPOSAL PONDS ❑ 'I <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, 1 shall not <br /> employ any person In such manner as to becomesI{bject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performattce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Califon <br /> The appkieant ust :2 1 it in pections. Complete drawing on reverse side. <br /> Signed x <br /> Title: Date: <br /> ----�_ FOR DEPARTMENT USE ONLY <br /> fo Date <br /> Application Accepted by ---_ Area S- <br /> qO <br /> Pit or Grout Inspection by Date Final lnspecdon by Date _C <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 I AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br /> INFO ���'7777� / /y <br /> . 1:H 13.24 IREV.t INFO VU � IS L /0 ~�`-•'r <br /> EH;�•2a <br />