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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 O BOR 2009, STOCKTON, CA 95201 <br /> STT MIRE3 1 YEAR FROM DATE ISPUED <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 3.862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services/. f® �y� /� / ® City 'A'� 6 Lot Size/Acreage <br /> Job Address ... - <br /> Owner's Name 11+11 ,$/9S,*/< !/ Address ©/ �' �i��ti � Phone <br /> a / <br /> Contractor /T�/G� ` Address o� �� ��'��'� License Nor �! � Phon . <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT [ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 <br /> Cl Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. at Well Casing <br /> C7 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'l Public to Other fl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump _.516CA - H.P., State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Miterial & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I tDESTRUCTIO"N i I INo 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 - <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg .C,6pac1ty No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number •Jlw <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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, l 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 compensa- <br /> tion laws of Califor a." <br /> TheaapplicaLt us ca I r all requui ed inspections. Complete drawing on reverse sided <br /> Signed X �'<�� Title: � �s��i�2 Date: <br /> \\1DEPARTMENT USE ONLY �lf `I <br /> Application Accepted by C OA;zj �, �a" Date V ) Area + <br /> Pit or Grout Inspection by Date Final Inspection by <br /> M (o Dated <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 MOUNT DUE AMOUNT REMITTED CF41 <br /> RECEIVED BYINFO <br /> EH t3.74{REV. in51 5j' 0 �s.� / 13 <br />