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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 /> iPMWIT EXPIRES 1 YEAR FROM DATE ED <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 /> Joh Address i! City����U Lot 31ze/Acreage <br /> Owner's Name Address Phone <br /> j <br /> 'Contractor 6ge� -Address ole License No IP6,nr 'idL Phone <br /> TYPE OF WELL/PUMP: ii NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION Cl Out of Service Well ❑ <br /> i PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER d 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 SPECIFICATIONS67 <br /> C7 Industrial ❑Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fa Domestic I Private El,Gravel Pack 0 Tracy Type of Casing Specifications <br /> 1'I Public (-I!Other F1 Delta Depth of Grout Seal Type of Grout <br /> — <br /> I I Irrigation "_Approx. Depth I I Eastern Surface Seat Installed,by - <br /> k Repair Work Done U Type of Pump H.P. S to Work Done <br /> Well Destruction O Wall Diameter Sealing Material & Depth <br /> s Depth Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION 1 I. DESTRUCTION I I iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> .»- <br /> Installation-will-serve:-..Residence-_.-Commercial-.��­OtherA. <br /> - -w»-�- <br /> t Number 0f living units: I Number of bedropms t—'��+—''} `• <br /> k '"""-'-' "'Character of soil to-ddeptfi of'31dib :iT""""om j I 'tom '.Water table depth <br /> ' SEPTIC TANK. ❑ 1 Type/Mfg Capacity, Ase 6" No. Compartments <br /> PKG. TREATMENT PLT.0 Meth6d of Disposal <br /> �? - <br /> Distance to nearest: � Well "s"` yFoundatian_ Property Line <br /> LEACHING LINE No. & Length'of.lines, l5ri � ' Total length/size 4 <br /> FILTER BED C7 j Distance to nearest: ;_Well 6�I�T Foundation Property Line �� <br /> 11 <br /> SEEPAGE PITS 11 'ii Depth Size _ f.` xNu er rig <br /> f SUMPS L1 ['Distance to nearest: Well r Foundation Property Line <br /> i DISPOSAL PONDS D <br /> j I hereby certify that I hove prepared this application and that t1ie w6tk_w11l be-done in accordance with San Joaquin county ordinances;state laws, and <br /> 1 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 ntit <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 /> 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 taws-of California." �t <br /> .d <br /> The applicant must^c+aWfor11 req�uZ�insWtions. Complete drawing on reverse side. <br /> Signed XTitle: pate:L� !�. �. <br /> OR D5PARTMENT USE ONLY <br /> II . <br /> Application Accepted by Date '-3�'� Area 4 <br /> Pit or Grout Inspection by Date Final Inspection by Da <br /> Additional Comments: �' r <br /> ,l <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, Stocktorx,-CA 95201 <br /> INFO FEE AMOUNT DtJI _w AMOUNT REMITTED.. _. ..CASH �sAEGICK 9VEA BY.� DATE PERMIT'Nt). <br /> . EH17.21(REV.hiHS) �,�L 1•.: �3.] �'. ? `° ` b " Vr°!4' l� ��� <br /> EH 11-2e <br /> s <br />