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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Rhk;E1Vr. <br /> ENVIRONNMTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 S E P 1 7 1992 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ENViRQNMENTAt. HEALTH <br /> FXMIT EXPIREgi I YEAR ERQM DATE PERMIT1 ERVICES <br /> (Complete in Triplicate) <br /> Application is hereby wade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade 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/f {!� ,/^ <br /> Job Address 2 cb`�/ _ ///G2-r' Ate/` _- City r of Size/Acreage <br /> OF <br /> Owner's Name Address 21fff Phone " <br /> Contractor Address ��J� ]r/ !t se No. 5r s5" Phone g'6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.0 Monitoring Well C7 <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i"I Public C1 Other n Delta Depth of Grout Seal Type of Grout <br /> I l Irrigation — Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done A Type of Pump H.P. State Work Done r <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth =killer Materiel & Depth ✓ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADOtTION i I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> 1 available within 200 feet.) <br /> Installation will serve: Residence_ Commercial T Other <br /> Number of living units: Number of bedrooms 4 <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: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t - <br /> SEEPAGE PITS 11 Depth Size Number <br /> E "'SUMPS [.I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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 /> Thea applicant must all for I r <br /> pp e4uir in ctions. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> i FO P T USE ONLY <br /> Application Accepted by Date Ar eta <br /> Pit or Grout Inspection by Date Final Inspection by Dat Z <br /> Additional Comments: <br /> i <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 t <br /> INE AMOU/N/T;JDVE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> EH 14.21 IREV. <br /> E �� <br /> H tk2e <br /> i <br />