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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r <br /> rENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXP RES 1 YEAR FR M D <br /> (Complete in Triplicate) <br /> Thi <br /> 'Joaquin County for a permit to construct and/or install the work herein described. <br /> Application is hereby made to San. with <br /> with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is made in compliance <br /> (_.Joaquin County Public Health Services. <br /> City U �Lot size/Acreage <br /> Job Address oe} _ <br /> _ � f ,�� _ Phone <br /> Owner's Name f.S Address ,-�-- <br /> Conttactnr Address <br /> License No. Phone <br /> TYPE Of WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Servide Well ❑ <br /> OTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ <br /> PROP. LINE <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Specifications <br /> Cl Domestic/Private El Gravel Pack ❑ Tracy Type of Casing <br /> Type of Grout <br /> 1 n Delta Depth of Grout Seal <br /> I'! Public 17 Other r <br /> I i Irrigation —.Approx. Depth f I Eastern Surface Seal Installed by <br /> W <br /> H P State Work Done <br /> Repair Work Done U Type of Pump Sealing Material & Depth <br /> Well Destruction ❑ Well DiameterFiller Material 6 Depth <br /> Depth <br /> stem perm <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR IADDITION l I DESTRUCTIONavailablelwithin 200 feet.) if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> f SEPTIC TANK. ❑ Type/Mfg' Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. Ll <br /> Distance to nearest: We <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengthtsize <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS <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 /> nature certifies the following: "i certify that in the performance of the work for which this permit is issued, t shall not <br /> Home owner or licensed agent's sig <br /> employ any person in such manner n to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"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 California." <br /> The applicant must call for all reqOats: <br /> required inspections. Complete drawing on re rse side. J <br /> Signed X �1-�/--�P ' � Title: �P <br /> r FOR DEPARTMENT.USE ONLY. <br /> Date V lJ Area <br /> Application Accepted by "7 <br /> PDate ,. Final Inspection b D <br /> Pit or Grout inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health `[ <br /> r Services, Environmental Health Permit/Services �`• <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> I FEE AMOUNT DUE+ CASH AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. <br /> INFO . <br /> � —f <br /> �� ,ham lsFl 2��9a <br /> . EH 13-24 IREV.t n SI �r <br /> EH t4.2a <br /> i - <br />