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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> Job Address City of Size/Acreage dd�� <br /> f f � eS <br /> Owner's Name Phone <br /> f� <br /> Contractor dress f icense No.!/ <br /> Phone <br /> TYPE OF WE L/PU NEW WELL ❑ WELL REPLACEMENT C_ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C} OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom Cl Manteca Dia. of Welt Excavation Dia. of Well Casing <br /> ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public D Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth C <br /> Depth Filler Material epth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION ( DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Re idence+ Commercial_ Other ; <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 No. Compartments <br /> PKG. TREATMENT PLT. ❑ a - Methodof Di osa1 <br /> Distance to nearest: Well / � ndation � Property Line s <br /> LEACHING LINE Cl No. & LengtWof lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS CI DistanEce to nearest: Well E�A - ndation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <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 jar 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 subcontracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons'subject to workman's compensa- <br /> tion laws of California." <br /> The applicant rpust calf-for all requinspections. Complet drawing on r verse side. <br /> Signed X Title: 4� rl Date: <br /> _Zr <br /> 2� ` FOR DEPARTMENT USE ONLY C� <br /> Application Accepted by Date r hqh^ <br /> Area �2_I ell ! <br /> Pit or Grout Inspection by Date Final Inspection by r'l Date <br /> '' • C . L <br /> Additional Comments: A2, <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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH13-24 tREV.t I n 31 + 1 I l'f <br /> EH 94.26 1 r a <br />