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j APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HA2TLTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXP RES 1 YEAR FROM DATE LgaM <br /> t (Complete in Triplicate) <br /> i <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> i 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 /> t � City 1����-- Lot Size/Acreage T`!2/k, -- _— <br /> I Job Address <br /> Owner's Name <br /> ddress &I - Phone <br /> Contractor Address <br /> License Nm `S?u/Phone <br /> � <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> iii OTHER ❑ Monitoring Well C] <br /> t.r 4 i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f] Industrial Pe Specifications <br /> Cl Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing <br /> Cl Public, to Other f-1 Della Depth of Grout Seek <br /> Type of Grout <br /> __..Approx. Depth I I Eastern Surface Seal installed by D , <br /> I I IrriHatipn N <br /> Repair Work Done 0 Type of Pump H.P. State Work Dana <br /> Sealing Material S Depth of <br /> Well Destruction ❑ Well Diameter Filler Material d Depth <br /> Depth t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION Vel,- DESTRUCTION I I (No septtiailablec systthinem <br /> permitted if public Bawer is <br /> t Installation will serve: Residence d Commercial Other <br /> Number of living units: _J_ Number of roams p <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. TypelMfg Capacity �2- No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well + ' Foundation �30 Property Line <br /> LEACHING LINE L�o. & Length of lines ' Torsi length/size <br /> fi f y Foundation t Property Line - <br /> FILTER BED 11 Distance to nearest. Well — — <br /> I SEEPAGE PITS it-'Depth ' t -.Size S 4 � � Number �� f <br /> r SUMPS Ll Distance to nearest: Well d Foundation, Property Line <br /> DISPOSAL PONDS ❑ 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, an <br /> rules and regulations of the San Joaquin County 1 ti^ _ <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 /> empioy any person in such mariner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following; "l 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 appfi nni must call for all re fired inspections. Complete drawing on reverse side. 4r <br /> Signed f Title: _ G[/.t. /� Y _fi A T <br /> Date: <br /> J <br /> USE ONLY <br /> FOR DEPARTMENT U <br /> �. <br /> Ares <br /> Application Accepted by <br /> Date i <br /> ' Date S2- C Final Inspection byDate <br /> or Grout Inspection by ` yA <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 CASH RECEI BY DATE PERMIT N0. <br /> INFO q <br /> CL —�✓/y� <br /> + EH t3-24IAEV.1 85 <br /> EH t1.1e <br />