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l <br /> _.- APPL I CAT I OH FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> Ot? `Iqo-( 7 f <br /> PERMIT EXPIRES I YEAR FROM DATE .SSUSD <br /> -� (Complete in Triplicate) / -3 1 <br /> Application is hereby made to San Joaquin County,ror':a perdit to construct and/or Install the work erein described. This <br /> quin Cointy,Ordinance No. 549 and.1862 and the Rules and Regulations of San <br /> application is made in compliance with San Joa <br /> Joaquin County-Public Health Services. <br /> yaLZ+ kwtai City Lot Size/Acreage <br /> Jnb Atld�ess - ! <br /> r -Phone <br /> .� Owner's Name s <br /> ILicense No! Phone / <br /> Contractor Address ' <br /> TYPE OF-WEL /P M NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out or Service Well LI <br /> Monitoring Well C7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ^n <br /> j T{*DISTANCE TO NEARE57: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS N <br /> �- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial D'Open Bottom 0 Manteca— Dia:of Well Excavation <br /> Specifications <br /> ( [1 Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> i'1 Public f-1 Other ''` �'i [1 Delta Depth of Grout Seal <br /> I I Irrigation Approx. Depth Cl Eastern Surface Seal Installed by <br /> r j H.P State Work Dane <br /> Repair Work Done ❑ Type of Pump _ <br /> Well Destruction C) Well Diameter <br /> ' Sealing Material & Depth <br /> Depth i Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ff REPAIRlADDITION l I DESTRUCTION i l INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_. Commercial , <br /> __�j�.-_� t a G. <br /> Number of living units: Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet: Water table-depth <br /> ' <br /> SEPTIC TANK. ❑ Type/Mfg Capacity 'No. Compartments <br /> + Method of Disposal <br /> PKC. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation Property Line <br /> _,,,,LEACHING ® <br /> LINE ❑ No. & Length of lines Total length/size <br /> iFILTER BED ❑ Distance to nears Well Foundation Property Line <br /> 4 4 _ <br /> 0 SEEPAGE PITS I I Depth Number <br /> { . c <br /> LIMPS Ll Distance [o nearest: Well.��_ Foundation�...._.._ Property Lina <br /> ri 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 /> y that in the performance of the work for which this permit is issued, k shat)not <br /> Home owner or licensed agent's signature certifies the following: "I certif <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 /> S The applicant must call for all requir d inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: . _ Date: <br /> I FOR DEPARTMENT USE ONLY <br /> Date � � Area — <br /> Applic n Accepted by <br /> rout ins ction by Oate a Final Inspection by ate <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 ASN RECEIVED E3Y DATE PERM11.No. <br /> INFO UPJ <br /> + EH 13-24(REV.rin5) <br /> FH 31.2E r , <br />