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r <br /> 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 BOA 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DATE ED <br /> I (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 co.wliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �./ <br /> Lot Size/Acreage <br /> p ii. City <br /> ' Job Address <br /> I� Address Phone <br /> Owner's Name __G I� — L, <br /> Contractor <br /> �� rasa <br /> cense No.1 <br /> Phone D <br /> TYPE OF WELL/P MP' NEW WELL ❑ WELL REPLACEMENT C=1 DESTRUCTION ❑ Out of Service Well LI <br /> PUMP INSTALLATION El <br /> REPAIR ❑ <br /> OTHER ❑ Monitoring Well ❑ <br /> DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n industrial ❑jOpen Bottom ❑ Manteca Dia. of Wel! Excavation <br /> D Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> t <br /> i"1 Public i-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> - <br /> I I Irrigation I ..Approx. Depth l I Eastern Surface Seal Installed by <br /> ! -. _ <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> 'f Sealing Material & Depth I <br /> Well Destruction ❑ Well Diameter <br /> DIIPlh Filler Material & th <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADOITION ave DESTRUCTION l I septic system permitted if public sewer is { <br /> available within 200 feet.) v <br /> j Installation will serve: Residence— Commercial— Other r <br /> Number of living units: VNumber of bedrooms <br /> Water table depth <br /> Character of soil to a depw of 3 feet: <br /> SEPTIC TANK ❑ is TypelMfg Capacity—. No. Compartments <br /> PKG. TREATMENT PLT.❑ 2Method of Disposal <br /> Distance to nearest: Well a e!S Property Line <br /> I <br /> LEACHING LINE ❑ .No. &�Len�gthofines Total length/sizeFILTER BED ❑ distanto nearest: Well- ��ation ° Property Line <br /> SEEPAGE PITS l I Depth , Size _ Number <br /> SUMPS Cl Distance to nearest: Well <br /> jjjZ�datwn,, <br /> 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 <br /> Homeowner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this permit is issued, !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 /> I 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." 11 <br /> Theapplicant t call im r aire i spec ions. Complet drawing on r arse side. <br /> Date: <br /> Signed Title: <br /> I� FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> � Date Area � <br /> Pit or Grout Inspection by Date final Inspection by r Date f <br /> Additional Comments: <br /> I! <br /> Applicant - Return all1copies to: San Joaquin County Public Health <br /> d. Services, Environmental Health Permit/Services <br /> l I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. <br /> INFO <br /> � EH13-Y41REV.tin51 �� M <br /> ti q� a i <br /> EH 14-2e <br />