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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 /> DT2RNTT EXPIRES 1 YEAR FROM DATE-_ ]LED <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jab Address City ®�"'"'' Lot Size/Acreage <br /> Owner's Name O 1) Address I� y Phone <br /> Contract � r Address RIO, A 4,xI la r License No.�Z-�2ZCa Phone��4�s�Os <br /> TYPE OF WELL/PUMP: NEW WELT. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C1SYSTEM REPAIR C} OTHER C) Monitoring Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />' Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> V1 Public t; .,D Other n Delta Depth of Grout Seal Type of Grout <br /> � 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 D Well Diameter Sealing Material &-Depth <br /> " , Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EPAI DDITION { 11 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet,I <br /> a Installation will serve: Residence Commercial_ Other <br /> Number of living units: _a_ Number tedroams Z �A <br /> Character of soil to a depth of 3 feet- Water table depth rw <br /> SEPTIC TANK. -26, Type/Mfg Capacity/,20 No. Compartments J�\ <br /> PKG. TREATMENT PLT. ❑ r r Method of Disposal <br /> Distance to nearest: Well 15D__ Foundation /d Property Line s <br /> LEACHING LINE ,iK� No. & Length of tines Total length/size P <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> e " r <br /> u [r U rr <br /> SEEPAGE PITS `lX Depth 115 --Sixe y -�-Number <br /> SUMPS LI Distance to nearest: Well JPOr.,^ Foundation 1 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall net�J <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 raj <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 California." <br /> Theapplicant st call f 11 r quired inspections. Complete drawing on reverse side. <br /> Signed X Title: �� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area / <br /> t <br /> e <br /> or Grout Inspection by DatFinal Inspection by <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 REMITTED CK RECEIVED BY DATE PERMITNO. <br /> INFO ` �J� CASH <br /> EH 13-24 tREV.r/R 55 4 I t�6D m ,z A <br /> EH i1-26 tt <br />