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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. , PRONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EMIT EXPIRES 1 YE R FR M D T <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 No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> L ' 7 City.A� Lot Size/Acreage <br /> Job Address <br /> Owner's-Name �/� Address <br /> { ( �C PA v4 Phone E2 2 <br /> S c--z� <br /> c Contractor.- Address License No. Phone <br /> TYPE OF,WELL/PUMP: „'�}.N1 W W_ELL_rCI WELL REP.LACEMENT_1__1_. DESTRUC_T10N._ Out of:Service Well Cl <br /> PUMP INSTALLATION 0 �r SYSTEM REPAIR ❑ '1 .--_-j <br /> OTHER _ Monitoring Well <br /> J1, �y <br /> DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL�FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11�) �i J-;I t. <br /> Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation I -- f?ia:af,Well Casing tt <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. ' ""5pecifications <br /> - raui <br /> I'I Public Cl Other I fl Delta Depth of Grout Seal Type a} Gi <br /> I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Clone 0 Type of Pump H.P. State Work Done <br /> ' Sealing°.Material & Depth <br /> Well Destruction ❑ Well Diameter i U <br /> Depth f Filler Materia. & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION-t I F DESTRUCTION I I INo septic system permitted it public sewer is <br /> .,,_t, available within 200 leet.l <br /> Installation will serve: Residence— Commercial_ Other r ci <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type!Ifg ' Capacity No, Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well I Foundation Property Line <br /> i <br /> LEACHING LINE Cl No. & Length of lines { Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well i Foundation Property Line _T <br /> DISPOSAL PONDS ❑ <br /> E 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 foil g: "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 lif nis." <br /> I The ap ust cal f all re ui inspections. Complete drawing on reverse side. / C� <br /> Signed Title: <br /> OF <br /> Dale: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date Aoba <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: I <br /> i <br /> I Applicant - Return all copies to: San Joaquin County Public Health <br /> 1 Services, Environmental Health Permit/Services <br /> I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> JNFAMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE <br /> . EH 12 (REV.v Z X 5 R=�a) <br /> EH 14,�.2B <br /> i <br />