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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY•PUBLIC HEALTH SERVICES <br /> ENV I RONldENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 j <br /> �k P O BOX 2009, STOCKTON, CA 95201 <br /> 1-YEAR FROG DATE ED <br /> I (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 /> an <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of S <br /> Joaquin county Public Health Services. f 7 7 <br /> <'Lt City4Lot Size/Acreage 1 <br /> Jab Address � I <br /> Gt dress eL 17Y-3260 <br /> Phone <br /> Owner's Name j <br /> �� License No. 4 � Phone <br /> Contractor dress + <br /> TYPE OF WELL/PUMP: NEW WELL C� WELL REPLACEMENT l7 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 <br /> OTHER C3 Monitoring well <br /> SEWER LINES DISPOSAL FLD. PROP. LINEr <br /> DISTANCE 70 NEAREST: SEPTIC TANK PITSISUMfPS __-LI <br /> i - FOUNDATIONS AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 1T <br /> fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> C7 <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy -.Typeof Casing-- <br /> Type of GrouE <br /> r = II <br /> {'1 Public f7 Other f-i Delta Dep <br /> of Grout Seal .� <br /> I I Irrigation _.Approx.}Depth I I Eastern Surface Seal Installed by <br /> H P [ State Work Done ,S <br /> Repair Work Done ❑ Type of Pump Sealing Matei-isl &'Depth <br /> Well Destruction ❑ Well Diameter _Filler.Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION { REPAIRlADDITION I I DESTRUCTION I I (No seavailabptic <br /> 200 feetrsystem �)ed if public sewer is <br /> r installation will serve: Residence v Commercial— cher r X ' <br /> I Number of.living units: __/_ Number of b o s <br /> Water table depth <br /> Character of soil to a deof 3 feet:a <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. C] Method of Disal <br /> sp� <br /> Distance to nearest:, Well l t Foundation Property Liner),_ <br /> t ' <br /> <'LEACHING LINE 1111' No. 8 Length"of-lines_, Q <br /> Total langthlsize <br /> FILTER BED ❑ Distance to nearest: Well �� - Foundation Property Line 1 <br /> i u1M1r.• l <br /> _ Number iD ` 1D r x l <br /> SEEPAGE PITS I I Depth Size 1 �t f <br /> III SUMPS <br /> Distancetonearest: Well_`�10 Foundation f�� Property Line <br /> DISPOSAL PONDS ❑ r <br /> that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application 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 pertormance of the work for'wtiich 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 subcontracting 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 /> I The applica u r al i d ins tions. Complete r wing on reverse ide, <br /> Signed X Title: ---Date: 31 <br /> ' r OR DEPARTMENT USE ONLY ` <br /> R <br /> Date Area <br /> a ` 1 <br /> �Application Accepted by <br /> D <br /> Pit or Grout Inspection by <br /> Date Final Inspection by ate <br /> Additional Comments: <br /> Applicant - Return-all copies to: San Joaquin County Public Health t <br /> i Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 0 <br /> FEE CK RECEIVED BY DATE PERMIT•NO. <br /> ` INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> . EH!9.2�IREY.r�++51 <br /> 3/�Yo "la`7�� <br /> k EH 14.2e <br />