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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)46$-3420 t <br /> I P O BOR 2009, STOCKTON, CA 95201 <br /> `� PFJWJT EXPIRES 1 YEAR FRQM DA SD <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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. J <br /> Job Address00 City Lot Size/Acreage / <br /> t�� Address �� Phone <br /> Owner's Name / ;�toq <br /> Conti acta <br /> (s'1VS5 1 ull'?4 _ Address 963-Al ��h� License No. �7y Phone2 ~a0,41 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r3 DESTRUCTION Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q <br /> 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 i <br /> L-1 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Grave! Pack CTracy Type of Casing Specifications <br /> I'1 Public fa Other i C1 Delta Depth of Grout Seal Type of Grout <br /> i <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter i M Sealing Material & Depth <br /> Depth C 3 t7 Filler Material & Depth r <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION 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. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS E1 Distance tc nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 cenifies 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 per subject to workman's compensa- <br /> tion laws of California." ` <br /> The applic nt call for al s ired inspections. Complete drawing on reverse side. j <br /> E Signed Title: _ Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Zr Araa <br /> Pit or Grout Inspection by Date Final Inspection by Date yZ- <br /> Additional Comments: <br /> Applicant - Return all copies to: Sass Joaquin County Public Health <br /> Serviced, Environmental Health Permit/Services <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO, <br /> INFO f /� <br />