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I APPLICATION FOR PERMIT <br /> r <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 /> pEMIT-EXPIRES 1 YEAR FROM DA ED <br /> + (Complete in Triplicate) <br /> t <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. is <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 Health Services. <br /> 07 City Lot Size/Acreage <br /> / Job Address <br /> e. � <br /> Owner's Name —� Address �� _. Phone <br /> T Address 5-7� 1 License No.YJ L O' VIS Phone 36f <br /> Contractor a� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION L) Out of Service Well � <br /> SYSTEM REPAIR D OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ <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 /> n Industrial El Open Bottom 13 Manteca Dia. of Well Excavation 'S Dia. of Wel! Casing <br /> Fl Domestic/Private D Gravel Pack ❑ Tracy <br /> Type of Casing \ \ , -_ Specifications <br /> FI Public ill Other n Delta y� Depth of Grout Seal ♦ Type of Grout <br /> €i I i Irrigation �.Approx. Depth 1 I Eastern Surface Seal instakled by. <br /> ry -• State Work Done_ <br /> Repair Work Done •0 Type of Pump H•P. <br /> Well Destruction'�K,1❑ Well Diameter <br /> �. SealinAsilal <br /> rial & Depth <br /> Filler & DepthDepth . - 1r t <br /> i. TYPE OF SEPTIC WORK: NEW INSTALLATION 4 I --REPAIR/`ADOITION V DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: _ Number of bedrooms , <br /> Character of-soil'to a depih of 3 feet: " Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg ` yCapacity No. Compartments . ��� <br /> PKG. TREATMENT PLT. ❑j Method of Disposal <br /> ; • ; 5 el- <br /> i Distance to nearest: Well :�p U Foundation a Property Line <br /> LEACHING LINE D "No-8i Length-of-ii es f— Total length/size <br /> FILTER BED C] Distance to nearest: Well�/ — Foundation - -- Property Line <br /> ! SEEPAGE PITS I I Depth Size" h Number <br /> r <br /> SUMPS LI 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 t <br /> 1 Home owner or licensed agent's signature certifies the following: "I certify 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 compensa- <br /> tion laws of California." " <br /> The applicant_ us call all f - it in"plions. Complete-drawing'on reverse side�� -0" <br /> t Date: Ile <br /> Title: <br /> Signed X l <br /> FOR DEPARTMENT USE ONLY..---_- �- <br /> Application Accepted by Date - Area 7 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERM17'NO. <br /> INFO �y <br /> a EH 13-21 IREv.1/n Sl v" 1�t� �.' ct 1 <br /> EH',4.26 <br /> c <br />