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r <br /> 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 /> PF MIT 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 comatllance with San Joaquin County Ordl'nance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Gity Lot Size/Acreage <br /> Owner's Mame ddress ` Phone f <br /> ContractorR/e Address License No. Phone <br /> TYPE OF WELL/PUMP NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service <br /> Well <br /> PUMP INSTALLATION O SYSTEM REPAIR L-I ;t j'I • `, OTHER C;; Monitoring Well <br /> '. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESZ <br /> DISPOSAL FLD. PROP. LINE L <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> 1nduStnal ❑ Open Bottom 'CJ Manteca Dia. of Well Excavation Dia. of Welt Casing <br /> El Domestic/Private LI Gravel Pack Cl Tracy Type of Casing _ Specifications <br /> I'1 Public " ` - . (` Other I I Delta <br /> Depth of Grout Sea! Type of Grout <br /> l I IrriUauon -__ Approx,.Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done U Type of Pump ' H P <br /> -. State Work Done <br /> Well Destruction C Well Diameter Sealing Material Z Depth <br /> •� I t <br /> •'� Depth Filler Material iDepth- =•.. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I DESTRUCTION I I !No sapbc system permitted it <br /> r available within 200 feel) public sewer is <br /> Installation will serve: Residence �� Commercial___ Other <br /> Number of Jiving unlit: � Number of bedr ems <br /> r Character of toil to a depth of 3 feet <br /> Water sable depth J <br /> SEPTIC TANK 0 Type/Mfg Capacit 1 <br /> PKG TREATMENT PLT, n y No. Compartments <br /> Method of Disposal r �� <br /> F Distance to nearest: Well f _ Foundation d Property Line c _ 1v�I <br /> LEACHING LINE CI No. & Length of lines �- f <br /> T�.otal length/sire }} <br /> FILTER BED 1=1 Distance to nearest =Wells' d Foundation—c'L�� Property Line_ <br /> t <br /> SEEPAGE PITS J I I Depth Number \ <br /> SUMPS LI Distance 10 nearest: i1t <br /> Foundation . property Line <br /> DISPOSAL PONDS CI _ -J C <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- <br /> /,: ~ <br /> em 10 an :I certify that in the performance of the work for which this permit is issued. 1 shell not <br /> p Y V person m such manner as to become tubiept to w6rkman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the WoiV f6r which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." � , <br /> The appfican si I II regwr r spectioZ4,rn--1V <br /> drawing on re rs side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Appit5allon Accepted by ( �/ �� , <br /> Date ! Area <br /> on by -- Com' � <br /> Date /Final Inspection by�_ �/( //�/l Dets�s <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Ratelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> (7, ^ CASH RECEIVED BY DATE EPERM11O.EH13-2a111EVi�.si 1t� � 1 �( G.EH ;�Zs44—711- 9a3 <br />