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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1_YEAR FROM DATE 19SUED_ <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. �' �J <br /> Job Address o City � p6 Lot Size/Acrea.ge a� <br /> - <br /> Owner's Name 1t � �` -� Address ' Q� � Phor;e` � 3A <br /> ` f ?s <br /> t . .` <br /> Contractor 5;6-,6r- ddress_ eIcense IVo, �C �5.2�'_Phone <br /> TYPE OF WELL/PUMP: NEW WELL 11WELL REPLACEMENT. ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> 1 PUMP INSTALLATION';.O.` SYSTEM REPAIR.L) 'OTHER ❑ Monitoring Well �� I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD.-3. PROP. LINE <br /> FOUNDATION,- • - AGRICULTURE WELL OTHER WELL 1 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 i <br /> 0 Industrial ❑ Open Bottom f ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> F.l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> Il Public 1.1 Other 171 Delta Depth of Grout Seal Type of Grout t <br /> r <br /> I I Irrigation ___. Approx. Depth I. I Eastern Surface Said Installed by ` <br /> Repair Work Done U 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 REPAIRlADOITION I 1 DESTRUCTION { I lNo septic system pe(milted if public sewer is <br /> available within 200`feet.) / <br /> Installation will serve: Residence-4 Commercial_,r Other a <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> aJ No. Com <br /> SEPTIC TANK Type/Mfg Capacity Z Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: well ✓ __ Foundation CG Property Line ' <br /> LEACHING LINE Xr No. & Length of lines Total length/size411'r- <br /> FILTER <br /> r <br /> FILTER BED E-I Distance to nearest: Well Foundation Property Line # <br /> SEEPAGE PITS 1 1 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line ( t <br /> r <br /> DISPOSAL PONDS D <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 Countyr, k <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fo6.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 sub-contracting signature <br /> certifies the following: "(certify that in the performance of the work for which this permit is issued;!shall employ persons subject to workman's compensa- <br /> tion laws of California." i <br /> The applicant trust c r II wouired in pections/Complete drawing on reverse side. <br /> Signed Title: D <br /> FOR DEPARTMENT USE ALY <br /> _r� <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection b Date7` •� <br /> Additional Comments: <br /> 4 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 MOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> d a EH 13-24 1REV.V H Sf <br /> EH 84.20 <br />