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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION t <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> WIRES 1 YEAR FROM DAT � <br /> (Complete in Triplicate) <br /> Application In tall <br /> work <br /> in described. <br /> application is madebin cdompliance With SanJuin oatquinoCountyr Ordinancrmit to e No. 549struct gando1862eand theeRules andERegulations of Sans <br /> Joaquin County Public Health Services. [ j <br /> 7 5 t-S< Ct City Lot Size/Acreage ( a C e- <br /> Job Address . - <br /> Address Phone <br /> Owner's Name JJ <br /> [lam t 1! A Address�•� • �©� � ��2�License No.�3 Phone 3 6 ' 7 <br /> Contractor a <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ <br /> OTHER D Monitoring well <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r v I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATi N5 <br /> r� <br /> n Industrial �'Open Bottom ❑ Manteca Dia. of Well Excavation / r _ Dia. of Weil Casing <br /> Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications <br /> 1:1 Other f'I Delta Depth of Grout Seal / �100 <br /> Type f Grartf�� �' <br /> I'i Public �Irrigation P-0—Approx. De�p,th 1l Eastern Surface Seal Installed by i <br /> Repair Work Done. 0 ' Type of Pump 53, 1, H•P• tate Work one , <br /> /,, J� Sealing Materiel & Depth (AD J P" <br />` Well Destruction ,� Weil Diameter <br /> Depth /�� t Filler Material & Depth <br /> I i iNo septic system permitted if public sewer is <br /> ITIDN I i DESTRUCTIONP <br /> E TYPE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAIRlADD <br /> r Pavailable within 200 feet.) <br /> Installation will serve: Residence— Commercial ____ Other <br /> Number of living units: Number of bedrooms <br /> I <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 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line O <br /> SEEPAGE PITS 11 Depth Sire _ Number <br /> SUMPS a . Ll7 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, ana- <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 r <br /> not <br /> employ any person in such mann as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify at in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa-r . . <br /> i tion laws of Cat a." i <br /> V <br /> The applicaannt t call for I uir i spectio omplate drawing on,r arse side. <br /> Signed v Title: f��`'�'��� Date: <br /> e <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by00f Rate g" Area <br /> Pit or ro Inspection by <br /> a 2 Sf-�'G Final Inspection by Date C� . <br /> Additional Comments: <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> f Services, Environmental Health Permit/Services <br /> f 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK I CASH RECEIVED By HATE PERMIT NO.- <br /> INFO <br /> J. . EH 13-24 Ir1EV.r r x si 1 <br /> EH 24.26 115 `` <br />