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APPLICATION FOR PERMIT <br /> �A <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION j <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> ! P O BOR 2009, STOCKTON, CA 95201 <br /> IPE MIT EXPIRES 1 YEAR FROM DATE 15SUED <br /> (Complete in Triplicate) i <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 xith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Q <br /> Job Address 10CLO �� Lot Size/Acreage <br /> r <br /> Owner's Name Address Phone <br /> Contractor Address O License Ne. 3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D_ DESTRUCTION ❑ Out of Service Well ❑ h <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well CZ <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 /> D Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f.-i Domestic/Private 0 Gravel Pack Ll Tracy Type of Casing Specifications <br /> I'1 Public 0 Other f1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done (J 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 EAI ADDITION DESTRUCTION I k INo septic system permitted if public sewer is <br /> available within 200 feet.► a <br /> Installation will serve: Residence!i Commercial _ Other <br /> r, Number of living units: _Z_3 feet, of rooms' <br /> Character of soil to a depth of 3 feet: = Water table depth <br /> SEPTIC TANK. `fz< Type/Mfg.a Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ �s - L - C Method of Di sp sal <br /> } b0 Pro y -sp f <br /> Distance to nearest; Foundation pert Line <br /> LEACHING LINE No. & Length of lines w "--Total length/size <br /> FILTER BED C7 Distance to nearest: Well Foundation /© Pyaperty,Line i <br /> SEEPAGE PITS d Depth/ LIS ze Number <br /> SUMPS !LI Distance to nearest: `WellD� Foundation^ lQ Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the woork will be done in accordance with San Joaquin 'county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County Y_ <br /> Home owner or licensed-agant's signature certifies the following: "Iscertify4har 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 subject to work man%•compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fotlowing`: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Catifoinla." A e' <br /> Theapplicantm call for quifod inspections. Complete drawing'on re�arse Sida <br /> 'f Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY i <br /> ' Application Accepted by 01— v - —_ Date Area 2! <br /> � Pi�Grout Inspection by � �^ __ Date" <br /> _ ��"y Final Inspection by� h'' � � _ - Date <br /> �{ �o <br /> Additional Comments: ��" �� 421E-re4xs 'at IQp 4"�l o� cloy <br /> w <br /> Applicant - Return all copies to: San Joaquin County Public Health i <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE y AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> .r. Li <br /> EH 13-24 IHE%.t SI i <br /> EH;4.26 er <br />