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APPLICATION FOR PERMIT <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 /> PERUIT EXPIRES 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 <br /> application 1s 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 /> Job Address, / 34 15` en rCity ESCq Lot Size/Acreage <br /> Owner's Nameusf ei1 01 <br /> Address I`-c'� P �� Phone j <br /> Contractor Marhil pu Moo.OL s'#Address t° P–oQel License No. ���`��� Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well L <br /> PUMP INSTALLATION IN SYSTEM REPAIR L1 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK .7 SEWER LINES ?S DISPOSAL FLD. PRO?. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �� I <br /> [*-Domestic/Private IN Gravel Pack L7 Tracy Type of Casing Specifications <br /> I'] Public 1-1 Other ❑ Delta Depth of Grout Seal tV O r Type of Grout <br /> I i Irrigation —,Approx. Depth I I Eastern 1 Surface Seal Installed by <br /> Repair Work Bone O Type of Pump Sum H.P. _l fIZ _ State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRJADDITION_E,l__DE5TRU.CTION.I I. INo septic system permitted if public sewer is <br /> ' available within 200 feet.! <br /> Installation will seine: Residence_ Commercial Other <br /> Number of living units; Number of bedrooms <br /> 4 <br /> + Character of sail to a depth of 3 feet: Water table depth ` <br /> V <br /> ' SEPTIC TANK. ❑ Type/Mfg Capacity Na.•Compar%-ttents l <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property'Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well -Foundation Property Line <br /> f <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: Well SFoundation Property Line <br /> DISPOSAL PONDS CJ 5 <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 I a <br /> 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 applican st call for all required inspeet'o Complete rswing a reverse sid+f <br /> Signed Title: Date: <br /> r <br /> OR DEPARTMENT USE ONLY C� <br /> Application Accepted by Date f� Are <br /> Pit o Grout spection bv4Jate Final Inspection b 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., F 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> a EH 1124(REV,t/n$I13 11 7 <br /> EH i4.2g / O .. O <br />