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APPLICATION FOR PERMIT li <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOIL 2009, STOCKTON, CA 95201 <br /> .,,,..T EXPIRES 1 YEAR FROM DATE <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 kith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i Z! �'� Aja 1 Cit Lot Size/Acreage <br /> Job'Address <br /> C'¢G II <br /> Address Phone <br /> .57�/y7� ! s � .►T/�+ -�� ��.v rv. _'.� , <br /> Owner's Name It <br /> �� Address / License No.. � �Phone <br /> Contractor G f=s <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION UC0ut of Service Well LI <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 <br /> OTHER ❑ Monitoring Well [I <br /> 1. DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES <br /> A FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 11 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> L] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> T e of Casing <br /> C1:Domestic/Private ❑ Gravel Pack C7 Tracy Yp Type of Grout <br /> { l public 1-1 Other } fl Delta Depth of Grout Seal <br /> I Ilulrrigation �..Approx. Depth I 1 Eastern Surface Seal Installed by Q <br /> Repair Work Done ❑ Type of Pump H.P. State Work one_ <br /> Sealing Material & Depth <br /> Weil Destruction ❑ Well Diameter <br /> 'I Depth Filler Material & Depth <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic systhin m permitted if public sewer is <br /> I <br /> rinstallation will serve: Residence —4"Commercial____ Other <br /> Number of living units: Number of bedrooms <br /> ACharacter of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG . TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> + 3 ' Total length/size <br /> LEACHING LINE Cl No. & Length of lines <br /> +r <br />, FILTER BED G! Distance to nearest: Well Foundation Property Line <br /> SIEEPAGE PITS 11 DepthSize Number <br /> SUMPS LI Distance io nearest: Well Foundation Property Line <br /> piISPOSAL PONDS ❑ # <br /> l.`hereby certify that I have prepared this application and that the work willbe 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 for which this permit is issued, I shall not <br /> 4nploy 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 laws of California." a'�S�\ - �+ <br /> The applicant m t call for all require specti s. Complete drawing on reverse side. <br /> Signed X Title: Date:�^ z �d <br /> ��PARTM�ENT5E ONLY <br /> Application Accepted by ` Date , Area <br /> Final Inspection by- �r Date <br /> Date <br /> Pit or Grout Inspection by � <br /> lldditional Comments: ' <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> I i Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE � AMOUNT REMITTED CASH <br /> �j�y/ 7`-f0-.---A3 <br /> 31�� �o <br /> + EH EHyj�IREV.trHsi •L/V © * 1 <br /> IN <br />