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n 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 BO% 2009, STOCKTON, CA 95201 <br /> fpMWII RES 1 YEfiR FROM DAT9 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 cotiliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I4 � oL Size/Acreage r <br /> ob Address __ City <br /> til.. 4-� f A- 1< C2 Phone C1 <br /> Owner's Name, Address <br /> ontractor k ",eO ��f'1 Address 3 License No; Z Phone S- <br /> f TYPE OF WELL/PUMP: NEW WELL ❑ WELL. REPLACEMENT ❑ DESTRUCTION Out of Servce Well ❑ <br /> i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> j <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w <br /> INTENDED USETYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom C1Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public FI 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 <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence 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 FLT. ❑ k� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I Total len th/size <br /> r LEACHING LINE Cl No. 8 Length of lines f3 � <br /> FfLTER BED 0 distance to nearest: Well Foundation Property Line <br /> 4! <br /> SEEPAGE PITS 11 Depth, Size Number <br /> SUMPS EI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS- ❑ {l <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 /> 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 aiito 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 /> The applicant must all for allr quired irlgpections. Complete drawing on reverse side. <br /> Signed Title:T25 Date:� �- <br /> / FOR DEPARTMENT USE ONLY ` <br /> Application Accepted by Date S'� Area <br /> Pit or Grout Inspection by Date Final Inspection by �' Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> rI Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 <br /> CK 0 <br /> y FEE AMOUNT DtlE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> 150 <br /> 49r, N � <br /> . EM f3241REY.Yin n �� ��� II- h <br /> EF114-2tl J/ r b <br />