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d s R g <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i <br /> T 2NMIT EXPIRES 1_YEAR FROM DAIF 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 compliance :with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> )(Job AddressL_k A- City '�Lot Size/Acreage <br /> )(Owner's Nam Address Zan �n Phone -9 f <br /> ContractorAddress License No.•' Phone_ <br /> TYPE OF WELL/PUMP: NE <br /> tW WELL ❑ WELL REPLACEMENT n- ES <br /> DTRUCTION 0 Out of Service Well ❑ <br /> ". PUMP INS y TION ❑ SYSTEM REPAIR ❑ O Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SP D.+ PROP. LINE <br /> FOUNDATION <br /> . HICULTURE WELL 41—HER WELL.__L_ PITS/SUMPS _ <br />} INTENDED USE TYPE OF WELL PROBLEM ARE C UCTION SPECIFICATIONS <br /> n Industrial - ❑ Open Bottom L Manteca Dia. Well Excavation Dia. of Well Casing <br /> + D Domestic/Private `.:. Cl Gravel Pac� Ell y- Type of Casl � Specifications <br /> I'I Public ✓ 1-1 Other 171 Delta Depth of Grout Seal _ f Type of Grout D <br /> I I irrigation x. Depth l i Eastern Surface Seal Installed by '] <br /> Repair Work Done ype of Pump IH.P. State Work Do <br /> Well Destru ❑ Well Diameter�l Sealing Material & Depth t <br /> Depth ti Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTIONINo septic system permitted if.public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Numberr of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg f Capacity No Compartments <br /> PKG. TREATMENT PLT. ❑ i! Method of Disposal <br /> Distance to nearest: Well Foundation Property Line t <br /> A. <br /> LEACHING LINE D No. & Length of lines Total length/size. <br /> FILTER BED [_) Distance tot n earest: 'Well Foundation Property'Line <br /> I <br /> SEEPAGE PITS I I Depth ! Size Number i <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ .) 4 <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 shalt 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 /> The applieT/must call f all4e uired inspections. Complete drawing on reverse side. 2^ <br /> Signed - Title: C_1. = }fid Date: � <br /> FOR DEPARTMENT USE ONLY Q� <br /> Application Accepted byCzz� Date S'3 6 — p Ares a �+ <br /> Pit or Grout Inspection by Date Final_Inspection_b Do <br /> Additional Comments: 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 95201FEE <br /> ~ " <br /> INFO AMOUNT DUE AMOUNT 1REMlTFED CASH RECEIVED BY �r DATE PERMIT'NO. <br /> . EH 114-2a 324 1REV.f i x sl <br /> Eft �e ` 3d-q I <br /> V <br />