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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PEMIT EXPIRES 1 YEAR FR M DAT ED <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 /> C <br /> Job Address & /67, City Lot Size/Acreage f7 �-✓ <br /> Owner's Name O �Y /� Address Phone <br /> C <br /> Contractor409��_ <br /> G ddress License No. "rteRe <br /> TYPE OF WELL/PUMP: NTW WELL WELL REPLACEMENT ❑ DESTRUCTION LiDeft of Service Well' D <br /> r Monitoring Well <br /> PUMP INSTALLATION _SYSTEM REPAIR 0 OTHER ❑ ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD.'- PROP, LINE 1dG / <br /> FOUNDATION _ �D >� AGRICULTURE WELL OTHER WELL-/5)— PITS/SUMPS <br /> INTENDED USE' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION l� <br /> F1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> omesticlPrivate Gravel Pack 11 Tracy Type of Casing �� Specifications <br /> /I'1 Public FI Other I1 Delta Depth of Grout Seal lew Type of Grout <br /> I 1 Irritlation _25d� xpprox. Depth I I Eastern Sr ace Seal Installed by -��-- ---- - <br /> Repair Work Done C] Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Materiel & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADOITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is e'— <br /> available within 200 feet.I Q <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms �S <br /> Character of soil to a depth of 3 feet: Water table depth (1 <br /> SEPTIC TANK ❑ Type/Mfg �' Capacity No. Compartments• �1 <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation 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,.anc <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 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 <br /> ompentation laws of California." <br /> The applicant s ca r uirad i omplete drawing on r vse side. <br /> Signed X Title: Date: <br /> FO T-USE LY <br /> Application Accepted by Date _ Area <br /> Pit or ro Inepection by Dal Final Final Inspection by �- ate 6 <br /> Additional Comments: t <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 <br /> INFO AMO`UNrT DUE AMOUNT REMITTED] ASH CK i RECEIVED BY DATE PERMIT NO. <br /> 11 <br /> EH 13 21 I REV.1/N 51 3`� t�'J J 1 c 'O 1 7 �7 T c] <br /> EH 14-2e 1 <br />