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APPLICATIOIN"FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION { <br /> 1.601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> XP RES ] YEAR FR M ATEED i <br /> (Complete in Triplicate) <br />,"A lication is hereby made to San Joaquin county for a permit to construct and/or install the work herein described. This <br /> in County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> application is made in compliance with San Joaqu <br /> Joaquin County Public Health Services. <br /> � r �� mss_ <br /> �,+ City Lot Size/Acreage <br /> UVob Address <br /> '' \\ Address ��� S ��-.�== Phon <br /> Owner's Name <br /> ' \ � /V•G Address License Na. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL El REPLACEMEN ❑ DESTRUCTION C] Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REP Monitoring Well C3 <br /> R ❑ <br /> OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN <br /> DISPOSAL FLD. PROP. LINE j <br /> FOUNDATION AGRICULTUR WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C RUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> f_7 Industrial ❑ Open Bottom ❑ Manteca D' . of Well Excavation a <br /> e f Casing Specifications_ <br /> Cl DomesticlPrivate ❑ Gravel Pac C7 Tracy yp 9 Type of Grout <br /> V1 Public 1-1 Other n Delta Depth f Grout Seal <br /> I I Irrigation _Approx.hDepth I I Eastern Surface eal Installed by <br /> Repair Work Done 0 Type of Pump h H State Work Done _ <br /> Baling Material Depth <br /> Well Destruction ❑ Well Diameter ller Material & pth <br /> Depth <br /> TYPE OF SEPTIC WORK: NfW INSTALLAT N. REPAIRIADOITION I I DESTRUCTION l I available wit in m20 <br /> 00 feetHted if public sewer is 0 ; <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: L Number of bedrooms <br /> P Water table depth <br /> Character of soil to a dept�f 3 feet: <br /> SEPTIC TANK Type/Mfgt Grp Capacity- No. Compartrnents <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE P"No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well_ �� Foundation Property Line <br /> SEEPAGE PITS t@'I- Depth 25 ize 3 __ Number <br /> SUMPS LI Distance to nearest: WelFoundation Property Lina <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 Co my <br /> Home owner or licensed agent's signature certifles-the following: "I certify that in the performance of the work for which this permit is issued, k 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 California." <br /> The applicant must for all required ' lata drawing on reverse side. <br /> �._ <br /> Aignad x �z Date: <br /> FITMENT USE ONLY <br /> Date Area <br /> F <br /> f Application Accepted by <br /> it r Grout inspection by <br /> Dat r Final Inspection by Date <br /> Additional Comments: <br /> M 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 ,kMJliUNT REMITTED DASH Y RECEIVED By DATE PERMIT'NO. <br /> INFO (7�t, <br /> ' r q0-18L3 <br /> EH 19.24 IREV.rrw5l <br /> EH A-28 D O <br />