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APPLICATION FOR,PERMIT <br /> WIN <br /> SAN JOAQUIN COUNTY PUBLICHEALTHSERVICEN <br /> ENVIRONMENTAL HEALTH DIVISION N &.2 W <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-$4120. <br /> JUL <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> P IT ENVIRONMENTA.L HEALTH <br /> EXPIRES I YEAR FR DATE ISSP-M PERMIT/SERVICE <br /> (Complete in Triplicate) -$ <br /> APplication is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described.I This <br /> application is made In compliance With Ban Joaquin county ordinance No. 549 and 1862 and the Rule* and Be <br /> Joaquin County Public Health services. gulations of San <br /> Job Address <br /> CityLot Size/Acreage <br /> IV -/00aa <br /> Owner's Name Address <br /> k ewc Phone <br /> IVContractor Address ^License N4." Phone [1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [-I DESTRUCTION Ll Out of�Service Well <br /> O <br /> PUMP INSTALLATION f SYSTEM REPAIR 0 OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD,— PROP. LINE <br /> FO-UNDATION AGRICULTURE WELL — OTHER WELL— PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F] Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia, of Well Casing <br /> C1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications--- <br /> I P"blic EI Other n Delta <br /> Depth of Grout Seat <br /> I"." Type of Grout <br /> Irfigation 11 <br /> —.Approx. Depth I I Eastern Surface Saul installed by <br /> Repair Work Done L3 Type of Pump H.P. <br /> Well Destruction 0 Well Diameter V State Work Done <br /> Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 lNo septic system permitted if Public sower is– <br /> available within 200 feet.) <br /> Instatlation will serve: Residence Commercial— Other <br /> Number of living units: <br /> Number-of bedrooms <br /> Character of sail to a depth of 3 feet: <br /> SEPTIC TANK 0 Tvpe/Mfg Water table depth <br /> C8PacitY-------,�.-- No, Compartments <br /> PKG, TREATMENT PLT, 0 h. <br /> D I isiance 1 Method of Disposal <br /> o nearest: I I <br /> Well .,Foundation. Property Line-_ <br /> LEACHING LINE <br /> 0 No. & Length of tines <br /> FILTER BED n Distance to nearest: Well Foundation Total length/size <br /> Property Line <br /> SEEPAGE PITS I ) Depth Size <br /> SUMPSLI Distance to nearest: Number <br /> Wall :Foundation Property Line <br /> DISPOSAL PONDS 0 <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 SanlJoaquin 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 not <br /> employ any per on in <br /> such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting sigature <br /> certifies the ving: , certify that in the performance of the work for which this Permit is issued, I shall emplo <br /> i ornia.' y persons subject to workman's componsa- <br /> tion laws o <br /> The ap lic ust call re inspections. Complete drawing on evje side. <br /> Signed Title: Date: 7- 5 <br /> FOtREPARTMENT USE ONLY i <br /> Application Accepted by <br /> TP e-b JI 0YU—: Date Are <br /> Pit or Grout Inspection y Date :Fina:11nspection by 4�-r- <br /> Additional Comments., rcJ.1 Z Date <br /> Applicant Return all copies to: San Joaquin County Public Health <br /> ifs Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., F;0 BOX 009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT,DtJE AMOUNT REMIT-TED RECEIVED BY Dg <br /> TE TE PERMIT'NO. <br /> EH 13-24 1 REV.s/A 5) <br /> EH 14-26 LA 11 S 01J C) 9 <br />