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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 { -f3 <br /> l� <br /> i ti <br /> EXPIRES 1 YEAR FR MDA fi SD <br /> i (Complete in Triplicate) �� <br /> h <br /> Application is hereby made to Seen Joaquin County for a permit to construct and/or install the work e"rein�describ , <br /> application is made in compliance with San Joaquin County ordinance No. 5�9 and 1$52 and the Ruled.and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 <br /> Job Address i _ __m�'f Jh �� <br /> r _ Cityc7 Got Size/Acreage <br /> I� <br /> Owner's NameAddressz <br /> —. Phone <br /> Contractor Address License No. Phpne <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Dut of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well G7 <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 /> 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> f Cl Domestic/Private Cl Gravel Pack 0 Tracy Type of Casin g <br /> ' Specifications <br /> i I lrrianon I Public (D Other fl Delta Depth of Grout Seal Type of Grout <br /> U' _.Approx. Depth I I Eastern Surface Seal 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 CA <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUC I ION7I INo septic system permitted if public sewer is ' <br /> Installation will serve: Residence_rICommercial_ Other available within 200 feet.) I ' <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Q/r <br /> SEPTIC TANK ❑ Type/Mfg Water table depth 1/PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well f=oundation Property Line <br /> �I <br /> LEACHING LINE ❑ No. & Length of lines r <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 9 <br /> e� Property Line <br /> SEEPAGE PITS I I Depth i I Size <br /> SUMPS Number <br /> Ll Distance to nearest: Well Foundation Property Line V. <br /> DISPOSAL PONDS ❑ .� <br /> t hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 'I <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 as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: E <br /> "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 /> t <br /> The appli nt ust calf f all r iced ins i ns. Complete drawing on reverse side. <br /> Signed PP <br /> Title: Date: �� <br /> I <br /> �rOD�EMENT USE ONtY ' <br /> Application Accepted byDate 1 <br /> 4� Area <br /> Pit or Grout Inspection by Date' Final Inspection b Date <br /> Additional Comments: <br /> Applicant – Return all copies to: San Joaquin County Public Health s <br /> Services, Environmental Health Permit/Services p <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PEPM17'N0. <br /> . EH 13-24{REV.t K SI , / ` a <br /> EH.4.26 ,R > [ 0/ Ci <br /> k D <br /> r <br />