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ro , so <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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATES 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 62 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic s. <br /> Job Address r City Lot Site/Acreage <br /> Owner's NameAddress Phone <br /> ' r r . <br /> Contractor cess D cense No ! Phone <br /> TYPE OF WELL PUMP: NEW WELL ❑ WELL REP CEMENT i7 DESTRUCTION Li Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SY EM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW LINE DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRIC LT RE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Pia. of Well Casing <br /> ".l Domestic/Private O Gravel Peck ❑ Tracy Type of Casing Specifications <br /> "1 Public 1-1 Other 11 Dett Depth of Grout Seal Type of Grout <br /> I Irrigation —Approx. Depth 11 E tern Surface Seal installed by <br /> Repair Work Done t.] Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing terial & Depth <br /> Depth Filler Maters 8 pth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION Pr DESTRUCT)PN i I lNo septic system permitted it public suwer is <br /> � / n evade within 200 feet) <br /> Installation will serve: Residence w Commercial Other <br /> Number of tieing units: Number of bedrooms <br /> Character of coil to a depth of 3 feet: Water table depth C9 <br /> SEPTIC TANK ❑ Type/Mfg Capacity 120 It No. Compartments � <br /> PKG. TREATMENT PLT. ❑ Method of Ditpo I O <br /> Distance to nearest: Well_,'Q Foundation& Property Line <br /> LEACHING LINE C'. No. & Length of lines / T al length/size �l <br /> FILTER BED D Distance to nearest: Well Foundation -�SProperty Line t� <br /> SEEPAGE PITS 11 Depth 2 Size Number <br /> SUMPS ILI Distance to nearest: Well Foundation Property Line <br /> S <br /> DISPOSAL PONDS ❑ <br /> 1 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 shalt 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 rformance of the work for which this �} <br /> 9 Y P'e permit is iaaued, I shalt employ persons subject to workman's compensa- <br /> tion Iowa of California." <br /> The applicant 79st call for el uirsd i pactions. Complete drawing on reverse side. <br /> Signed a Title: 4!= L _ m Date: J ` 2 Q <br /> F ENT USE ONLY <br /> Application Accepted by Date + Area <br /> Pit or Grout Inspection by Date Final Inspection by Data U <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Envirommental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IN OUNT DUE AMOUNT REMITTED CASH RECEIVED <br /> /fBBY DATE PERMIT NO. <br /> . Eft 13-24 IRE ri x51 ^ 0,0 (� <br /> EH t�2e <br />