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s <br /> I` <br /> APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> _ P O BOX 2009, STOCKTON, CA 95201 <br /> P1PMIT EXPIRES I YEAR FROM DATE ISS-U_M <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 3 <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 r City Lot Size/Acreage <br /> Owner's Name <br /> Address r'1 Phone 3 33 - 7� <br /> 2 i/ <br /> Contractor ddress d � License No.��Phone 7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Dut of Service Well L1 <br /> PUMP INSTALLATION W-' SYSTEM REPAIR 171 OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL--- OTHER WELL PITS/SUMPS t <br /> INTENDED USE TY-K OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> niLnustrial Open Bottom ❑ Manteca Dia. of Well Excavati n Dia. of Well Casing a <br /> [YP <br /> omesticlPrivate C] Gra Pack*F —❑ Tracy Type of Casing �� '`"- Specifications <br /> 1'1 Public x Cl Other -. fl De to Depth of Grout Seal d Type of Grout t <br /> I I Irrigation Approx. Depth I+I'Eastern Surface Seal Installed by j <br /> Repair Work Done U Type of Purnri -� — H.P. - L - State Work Done <br /> Sealing Material & Depth <br /> Well Destruction Well Diameter ''= : , <br /> f Depth Filler'Material'& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: -Residence - -Commercial Other <br /> Number of living units: Number of bedrooms S u <br /> Character of soil to a depth of 3 feet: - Water table depth <br /> SEPTICTANK , ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ F <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING_LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I I Depth — Size Number <br /> SUMPS LI Distance to nearest: Well Foundation 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 /> Home owner or licensed agent's signature oenifies 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." Contractor's hiring or sub-contracting signature <br /> 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 compenia• w <br /> tion laws-of California." . <br /> The applicant must call for all rfired inspections. Complete drawing on verse side. <br />. signed ` rias: Date: <br /> : - '2- 9� <br /> O TMENT USE ONLY i <br /> - I <br /> Application Accepted by Date /J Are <br /> Final !ns action b / � Date =��(J <br /> Pit or ro t Inspection by ■ata - p Y <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 REMITTEDRECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH 13-24(REV.I/n SI <br /> (as;t,a <br /> EH 14.2los <br /> 6 <br />