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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 0 BOX 2009, STOCKTON, CA 95201 <br /> 'kERMIT EXPIRES_ 1 YEAR FROM DAIB ISSUED <br /> (Complete is Triplicate) <br /> Application is hereby made to San Voaquin County for a permit to construct and/or install the vork 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. <br /> Job Address /0 r'7 V �C.E�! 'C� _ City Lot Size/Acreage <br /> ` Phone X�Owner's Name l/ r Address <br /> x t <br /> Contractor , f-'—i l Address License No�6�7� Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of 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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T <br /> Cl Industr rial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications # <br /> I'I Publics Cl Other Fl Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation _.Approx. Depth I I Eastern Surface Seal installed by ` <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> I Depth Filler Material & Depth <br /> 5 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION VJ/DESTRUCTION I 1 INo septic system permitted if public saver is { <br /> available within 200 feet.) 1 <br /> Installation will serve: 'Residence v Commercial____. Other <br /> Number of living units: Number F'�'{bedroams 3_ / f <br /> - Character of soil to a depth of 3 feet: Water tablaidepth <br /> TANK ❑ Type/Mfg �of- <br /> SEPTIC Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Y Method of Disposal <br /> Distance to nearest: }Well Foundation Property Line <br /> LEACHINGLINE No. & Length of lines ' <br /> l Total length/.size <br /> �' _ <br /> FILTER BED 0 Distance to nearest: Well Foundation' �1- `property',Line <br /> SEEPAGEI PITS W Depth S e r-Ll lie - _ y Number 1 <br /> �Ln` t <br /> SUMPS LI Distance to nearest: !,Well . O r Foundation Ott< Propertyjune d� ! <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application anVihat the warklwill .�..be done in accordance 3wHft-; <br /> San Joaquin county ordinances, state-laws, and <br /> rules and regulations of the San Joaquin County. i" I' I <br /> Home owner or licensed agenf-�.sieghature_cenifies'the following: 'I certify that in the performance of the work for which this permit is issued,41 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 /> certifies the following: "I certify that in Eh_a performance of the work for which this permit isj� ued.1shall_employ persons subject to workman's compensa- <br /> tion laws of California." i <br /> The appli . st calf for all r uir inspections. Complete drawing on Averse side. <br /> Signed Title: Date: ` <br /> } <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by /�/ Date r /� � Area �� ! <br /> Inspection `L%Final Inspection by. ate <br /> � S <br /> /Piyor Groat ins ction by - Date <br /> Additional Comments: \4,i.�:- .-�•� *•,. <br /> Applicant - Return all copies to: San Joaquin County Public Health - f <br /> Services, Environmental Health Permit/Services i <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> r <br /> a EH 13-241AEV.r/r5i �� <br /> EH 14.2E <br />