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APPLICATION FOR PERIdIT <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 /> EXP RES 1 YEAR FROM. DATE IQgUED <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ��"f € Lao f, - P40 City Q fr •r1 Lot Size/Acreage <br /> Owner's Name tc � Address <br /> ,) Phone <br /> Contractor t t,.�r, Address 1`1 License NoC, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L] <br /> DISTANCE TO NEAREST: 'SEP—TIC TANK SEWER LINES — DISPOS-AL'Ft.-D:' PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public D Other ❑ Deus Depth of Grout Seat Type of Grout <br /> I I Irrigation 4' �.Approx, Depth , t l Eastern Surface Seal Installed by r <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done �t <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I 1 {No septic system permitted if public sewer is <br /> Z <br /> Installapon will serve: Residence Commercial_ Other available within 200 feet.) <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_ -1.e. No. Compartments <br /> PKG. TREATMENT PLT. ❑ e Method of Disposal <br /> Distance to nearest: Well <br /> Foundation property Line <br /> LEACHING LINE P No. & Length of lines 'R ~Total length/size Y <br /> FILTER BED n Distance to nearest: Well !00 Foundation �C�_ Property Line _ <br /> SEEPAGE PITS I I Depth Size W_ __ Nlymber P <br /> SUMPS 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 ba.done in accordance-with San Joaquin county ordinances, state laws, and <br /> rules and regulations cf the-San-Joaquin County— <br /> Horne 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 /> tion laws of California." <br /> certifies the following: "I certify that in the pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> f <br /> The applicant must call for all required inspections. Complete drawing on reverse side, <br /> Signed X Title:> Date: <br /> i <br /> FO AHTIUIENT USE ONLY <br /> Application Accepted by tiff 9-9 <br /> DateArea <br /> Pit or Grout Inspection by Date ­Final Inspection bye Dater <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health �``� •, <br /> Services, Fnvirommntal Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FE f MOUNT DUE AMOUNT REMITTED — CK' <br /> INFO / CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 14-I5 1REV.�iH S� Lk I-0-0 <br />