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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 /> i P O BOX 2009, STOCKTON, CA 95201 <br /> 1 EXPIRES 1 YEAR FROM DAIR 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 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. y� <br /> �JobAddress <br /> City C]l"CY IL-14 Lot Size/Acreage <br /> t ► p, iv 1 l - Phones <br /> Owner's Name Address <br /> JE License No. ] t _ Phone L(,A 3�OS7 <br /> Contracta�..LU1� Address . <br /> TYPE OF WELL/PUMP.. NEW WELL 0 WELL REPLACEMENT C) DESTRUCTION ❑ Outlof Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM:REPAIR ❑ OTHER ❑ :Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTEN.DED:U_SE_s 'TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS ` <br /> F] Industrial ❑ Open Bottom_\ 0 Manteca Dia. of Well Excavation ;Dia. of Well Casing <br /> Cl Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public Cl Other ,❑ Delta Depth of Grout Seal Type of Grout <br /> Ii Irrigation Approx. Depth�*I_i Eastern Surface Seal Installed by <br /> Repair Work Dona 0 Type of.Pump .r .� H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth f filler Material & Depth J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I !EPADDITION I DESTRUCTION i I (No septic system permitted if public sewer is <br /> Jam/ IR! available within 200 feet,) ,10 <br /> Installation will serve: Residence'i Commercial—r�Other W. , z 0 <br /> Number of living units: Number of bqdr °oms L_ ' <br /> Character of soil to a depth-of 3 feet: I Water table depth S <br /> SEPTIC TANK ❑ Type/Mig �� F Capacity ` No. Compartments <br /> PKG. TREATMENT PLT. El <br /> of Disposal <br /> r Distance to nearest: ' Welles---"Foundation Property Line <br /> LEACHING UNE C1 No. & Length of lines Total length/size ' <br /> FILTER BED NO-Distance to nearest:' " Well Foundation Property Line <br /> SEEPAGE PITS Depth -Size_ _ 3(Q Number <br /> SUMPS LI Distance to nearest: Well t Sb Foundation t7 Property Line <br /> DISPOSAL PONDS ❑ <br /> 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-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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which iKis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m t call for al. quir inspections. Complete drawing on rover" <br /> si <br /> SignedTitle: Date: <br /> f FOR DEPARTMENT USE ONLY 2 <br /> Application Accepted bylie "i' Date�l Area _ <br /> .r <br /> i or Grout Inspection by Date Final Inspection by Date <br /> t <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 CK RECEIVED BY DATE PERMIT"N0. <br /> INFO CASH <br /> a <br /> CH 13-24IREV.1/N 5) ylS P �o =7rSZ1 <br /> t EH,4_4 <br />