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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 /> EXP RES 1 YEAR gR M D ID l <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.CoMliance vith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / ,, \ �— <br /> City �J� Lot Size/Acreage �]�1 <br /> Job Address <br /> C _ Address iz G � �I + � Phone <br /> Owner's Name + <br /> > � —:^ _ _ Phone <br /> Contractor �+ Address � --. License No <br /> TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLAlTION SYSTEM REPAIR 0 <br /> OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK L.� SEWER LINES DISPOSAL FLD. PROP. LINE f r' -r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS X0 .r s <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia, of Well Casing <br /> F_ <br /> Domestic/Private 0 Gravel Pack © Tracy Type of Casing _' Specifications X <br /> ', [� _ Depth of Grout Seal <br /> 7yRe f Grout <br /> I"1 Public I:1 Other Delta <br /> I l Irrigation I 0L.Approx. Depth I I Eastern Surface Soul-Installed by <br /> Repair Work Done ❑ Type of Pump — H.P. State Work Done <br /> Well Destruction C) Well Diameter <br /> Sealing Material A Depth <br /> Depth Filler Material & Depth , <br /> TYPE Of SEPTIC WORK: NEW IN I I REPAIR/ADDITION 1.1.,DESTRUCTION•LI INo septic-system_pecmitted if public sewer is <br /> available within 200 feet:) t . <br /> Installation will serve: Residence— Commercial._..^ Other <br /> f <br /> Number of living.units: ' <br /> Number of bedrooms <br /> Character of soil,ao_a dept��3-feeTrWater table depth <br /> SEPTIC WANK". Type/Mfg Capacity— <br /> . No. Compartments <br /> f Method of Disposal <br /> PKG. TREATMENT PLT. ❑ f-ri- <br /> ._. Distance to nearest: Well -�}-Foundation Property Line ine <br /> =x LEACHING LINE D No. & Length of-lines b Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number ' <br /> } SUMPS Cl. Distance to nearest: Well Foundation m Property no rt <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 m <br /> rules and reguietions of the San Joaquin County <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 /> f certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa <br /> r` tion laws of California." <br /> The applicant must call �alluired inspections. Complete drawing on reverse side. <br /> ; <br /> Signe X Title: Date: <br /> - R DEPARTMENT USE ONLY <br /> Application Accepted by _ Date y Area <br /> I <br /> Pit or�Gr ut Inspection by�. � `"Date Final Inspection bye Date <br /> Additional Comments: , <br /> i Applicant - Return all .copies to: San Joaquin County Publ c{Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK III <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT No.; <br /> INFO <br /> r EK 13-24(REV.I/N 5F <br />