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APPLICATION FOR PERMIT <br /> f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> 1 P O BOX 2009, STOCKTON, CA 95201 <br /> PERIdIT EXPIRES 1 YEAR FROM DATE �UED <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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatigns of San <br /> Joaquin County Public Health Service . <br /> Job'd` dress City Lot Size/Acreage / r <br /> Owner's Name ' ' �.. f hone <br /> rz D <br /> Contractor dress icense -c Phone <br /> ZZ <br /> TYPE OF WELL/P M NEW WELL 11 WELL REPLACEMENT Fff DESTRUCTION If out of Service Well. ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATiONF AGRICULTURE WELL OTHER WELL PETS/SUMPS <br /> INTENDED USE TYPE..OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> n Industrial 0 Open Bottom '+} ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> I.f7 Domestic/Private Cl Gravel Packi 8,C] Tracy Type of Casing� .. - � Specifications <br /> I'I Public i 1-1 Other , 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .' — Approx. Depths I I Eastern Surface Seal Installed.by y <br /> Repair Work Done 0 Type of Pump 'a H.P, # t State-Work Done <br /> Well Destruction ❑ Well DiameterA" r Sealing Material Depth <br /> Depth 4 t ;s0. Filler 44aterial pth i <br /> TYPE-OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION { I (No septic system permitted if public sewer is ' <br /> - I available within 200'feet.I <br /> �L` <br /> Installation will serve: Residence #Commercial___ giber <br /> Number of living units: ,-t— Numbeir of bedrooms <br /> Character of soil to a depth of 3 feet. f Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity &l No. Compartments <br /> PKG. TREATMENT PLT. 0 ...-..--Method <br /> D <br /> Method of ilkosal <br /> Distance to nearest: Well T..�_ Foundation --�-- Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER DED Cl Distance to nearest: Well Foundations Property Line - <br /> SEEPAGE PITS I 1 DepthSi:e � Number <br /> SUMPS L] Distance to nearest: Weil 44Poundation Property Line <br /> DISPOSAL PONDS © <br /> f <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 /> Home owner or licensed agent's signature'canifies 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 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 /> The applicant must cAl'for#4 requi inspections. C eta drawing on reverse side. <br /> Signed X Title: /(r 4 - Date: <br /> FOR DEPARTMENT USE ONLY �+ ,� <br /> Application Accepted by Date �,� ti °Area 12- <br /> Grout <br /> 2Grout inspection by ate Final Inspection by Dat <br /> f <br /> Additional Comments:, <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> i1601 <br /> E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 v <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT No. <br /> INFO CASH <br /> a EH 1 .24 IREV, <br /> EH 14.28 <br />