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APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 00 $L P, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1.601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> f P O BOX 2009, STOCKTON, CA 95201 <br /> PEMIT EXP RES 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 j <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 Healtherviic�es, 1���� <br /> 2491 dl �� City \ Lot Size/Acreage <br /> xJob Address n^,,� �1,, ��{g, (�� r� <br /> Owner's Name Q �Ntp► �"^"` Address ` � ""`Y�^ Phone ��%_W_' <br /> Contractor Address License ryo. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ervice Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ HER C3 Monitoring Well <br /> DISTANCE TO N EPTIC TANK SEWER LINES OSAL FLD. PROP. LINE <br /> FOUN AGRICULTU OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF-WELL P REA CONSTRUCTION SPECIFICATIONS s <br /> n Industrial C3 Open Botto ❑ Manteca of Well Excavation i Dia. of Well Casing <br /> tt f l <br /> Domestic/Private ❑ G ack ❑ Tracy Type of Specifications <br /> !'1 Public _1 Other R Delta Depth of Grout Seal _ Type of Grout <br /> I I Irrigation —.Approx. Depth ) I Eastern Surface Sea! Installed by n <br /> I H.P. State Work Done �y <br /> Repair ork Done L7 Type of Pump � <br /> Well Destruction ❑ Well Diameter Sealing Materiel & Depth <br /> Depth i s Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIRIADDITION I I DESTRUCTION (No septic system permitted ifpublicsewer is <br /> I i _ w- — available within 200 feet.) <br /> Installation will server Residence 1 Commercial— Other <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> . r <br /> SEEPAGE PITS 1 ) Depth Size Number <br /> SUMPS CI Distance to nearest: Welf Foundation Property Line <br /> DISPOSAL PONDS Cl # If <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, <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I cert#y that 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 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 compgnsa- <br /> tion laws ofalitorn)a." 4 <br /> i <br /> The applican must tall forI required inspections. Complete drawing on reverse side. <br /> Old Title: _ OWh. -_ Date: ��11AX Signed X - — <br /> FOR DEPARTMENT.USE ONLY <br /> Application Accepted by 12 a Date 4 Area <br /> "Pit-or Grdut Inspection by` '' "" Date Final inspection by Date <br /> Additional Comments: t i <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> .–=Services--•.Ravironmental -Health Pomi't/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> { FEE AMOUNT DUE AMOUNT REMITTED I ASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24[REV.I/H Sl W <br /> EH 74 24 <br />