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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 /> PEMIT EXPIRES 1 YEAR FROM DATE 19§UED <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 NQ. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �,,� <br /> Job Address �/Yu Cit�T ' _ Lot Size/Acreage <br /> O>PePs Name *Vj�ress=�tr�� p � Phone <br /> Contractor <br /> �. ! K � Addresss� N �anc� License Na? �' Z hone 7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CYl DESTRUCTION Frout of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> D Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications q <br /> 6'1 Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout +� , <br /> i I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done T �: <br /> -Well Destruction ❑ Wel! Diameter Sealing Material Depth o � up ~- <br /> ti K <br /> Depth _ _yF d Filler Material & Depth &o_EL, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is 4 <br /> available within 200 feet.l <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms ro <br /> Character 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: Wel! Foundation Property Line <br /> LEACHING UNE C} No. 81 Length of linea Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line Z <br /> SEEPAGE PITS 11 Depth Size r _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 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." <br /> The applicai=lll re re inspections. Complete drawing on reverse side. <br /> Signe Title: ( —, Date:, - <br />'` OR DEPARTMENT USE ONLY j <br /> Application Accepted by ` Date ���9 Area ` LI <br /> Pit or Grout Inspection by Date Final Inspection by Date�� <br /> Additional Comments: <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, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK I RECEIVED BY DATE PERMITN0. <br /> INFO CASH <br /> kk a EH 1321 IR EV.1)n5 ( 70 W© <br /> EH 11.29 Y CC a f7 <br /> 4 <br />