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APPLICATION FOR PERMIT H <br /> ,,SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �Ell <br /> ENVIRONMENTAL HEALTH DIVISION ��� � ���1 <br /> WD <br /> 1601 E. HAZELTON AVE. , PRONE (209)46$-342( <br /> P 0 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> Cr <br /> RMI�LEXPIRES -i-YEAR FR lt( )ATE ISSUED <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.COMliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> F Joaquin County Public Health Services. <br /> Job Address , <br /> City Lot Size/Acreage <br /> Owner's Na <br /> / (� <br /> r <br /> Phone f <br /> IC ntr c ifs, <br /> ease IVo. Phone <br /> TYPE OF WELL/PUMP: NEW WELL QWELL REPLACEMENT DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION: <br /> SYSTEM REPAIR ❑ OTHER p Monitoring well C7 <br /> 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE5- <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I XI" <br /> dustrial ❑ Open Bottom Q Manteca Dia. of Weli Excavation <br /> Dia. of Well Casing <br /> a estic/Private ❑ Gravel Pack 0 Tracy Type of Casing <br /> ublic f:7 Other` Specifications <br /> l� Della Depth of Grout Seal Type of.Grout <br /> r I I Irrigation Apprax. D th [ I Eastern ►face Seal Installed by <br /> Repair Work Done 0 Type of Pump . H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth State Work D <br /> t ; Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 .1 REPAIR/ADDITION I i DESTRUCTION i I (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial .--Other available within 21x3 feet.) 4 <br /> Number of living units: Number of bedrooms <br />` <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depthl <br /> © Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Lli <br /> Method of Disposal <br /> Distance to nearest: Well Foundation + <br /> I Property Line <br /> LEACHING LINE " <br /> `" 11"M1Io:& Length of:lines• '" -^�----�-- °--Total iehgthls"ire= <br /> FILTER BED ❑ Distance to nearest: Well �. <br /> r Foundation Property Line �. <br /> SEEPAGE PITS IJ Depth Size <br /> Number <br /> SUMPS r. <br /> CI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ ::/. i Property,Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San oaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agenfs'mignature 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." Coritractor's,hiring or subcontracting signature J <br /> certifies the following: , certify tha6n 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 applicant m cilli for it inspections. Complete drawing on rev Se sig da <br /> Signed <br /> Title: <br /> Date: <br /> FOR D PARTMENT USE ONLY { <br /> Application Accepted by U <br /> Date Area <br /> Pit or Grout Inspection by <br /> DataFinal Inspection by Date �3 <br /> 5 <br /> Additional Comments: <br /> Applicant - Return's-" 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 UUE AMOUNT REMITTEO Cx <br /> INFO CASHtZ BY DATE <br /> PERMIT'NO. <br /> EH 13-24 1AEV.i in sy <br /> EH 14.28 f <br />