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I <br /> 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 /> pg IT EXPIRES 1 YEAR FROM DA SUED <br /> Jam,,. (Complete in_Triplicate) ! 8 � (Q0 2— <br /> .r.l!2� t . <br /> Application is hereby made to San Joaquin County,for permit-to cons true t,,and/or install,th'e work herein described. This <br /> application is trade in compliance with San J6s4uin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. V <br /> Job Address ft ty Size/Acreage <br /> ■r f A C�J s <br /> Owner's Namn�-mom 1 U { Phone <br /> e <br /> r <br /> lContratta f Address ense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 111 .,f WELL REPLACEMENT El DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> .1', FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �J , <br /> n Industrial ❑ Open Bottom C] Manteca t Dia. of Well Excavation Dia. of Well Casing +� ` <br /> [I Domestic/Private 0 Gravel Pack ❑ Tracy I Type of Casing Specifications � <br /> l'} Public I:1 Other F1 Delta Depth of Grout Seal r Type of Grout e <br /> I i IrriOation Approx. Depth I I Eastern i Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.R. State Work Done <br /> Well Destruction O Well diameter Sealing Material-& Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION 11 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: Resi encs___._. Commercial her , <br /> Number of living units: T I' Number of bedrooms <br /> _ <br /> 7 L �i. .p. Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK &_-17pe/Mfg _ Capacity No. Compartments j <br /> PKG. TREATMENT PLT. ❑ r ) Method of Disposal <br /> - } Distance to nearest: WellFoundation Property Line ; <br /> LEACHING LINE5 & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well.. 5Foundation 42,0-L-- Property Line <br /> i <br /> SEEPAGE PITS Number <br /> SUMPS LI Distance to nearest: Well Foundation (� Property Line <br /> DISPOSAL PONDS ❑ <br /> l 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: "l cenity 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 /> oe ' les the followin : "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 /> tio law Califar a. <br /> The applicantt <br /> c II f al quir d ins ctr n late drawing�on=eversed <br /> ✓ r <br /> Signe Title: Date: <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> i 1 ] <br /> OAddit <br /> atlon Accepted by Date S Area <br /> r <br /> Grout inspection by 1�w� Date Final Inspection by y� ` - Date r� <br /> onal_Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> t Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> i FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. <br /> INFO l r A-6 <br /> � my <br /> « <br /> Em 13-24(REV.+/n5i 1 �-4' •u (� t C?"� 3 a `-r"� " 0 <br /> EH 14.26 1 1 <br />