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APPLICATION FOR PERMIT <br /> 51.6c s# S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA '95201 <br /> EXPIRES 1 YEAR FROM DA ED <br /> (Complete in Triplicate) <br /> 4 t <br /> Application is hereby made,to San.Joaquin County for a permit to construct and/or install the work herein described. This <br /> application ie made in compliance`vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. '1 <br /> 1 �,.�. Lot Size/Acreage <br /> Joh Address 233&' �- �,/--+�` +� city *� c I "" Phone <br /> Owner's Name Address , <br /> Contractor j D' Address License No. Phone <br /> TYPE OF WELL/PUMP: r NEW OELL ❑ WELL EPLAC7=MENT r] DESTRUCTION &Out of Service Well ❑Monitoring Well L� <br /> PUMP INSTALLATION El SYSTEM REPAIR 111 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC WK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> f-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �y <br /> i`l Public I:1 Other i� <br /> fl Delta Depth of Grout Sea! Type of Grout <br /> ! I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump WP. - '� i State Work Done <br /> sealing Material & Depth ► <br /> Well Destruction ❑ Well Diameter p`gt� <br /> Depth 1 Filler Material & Depth „ �ena C�.s�avt�,• �r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I i iNo septic system permitted it p[sblic sewerIsyy� <br /> t available within 200 feet.) T r V <br /> Installation will serve: Residence—' Commercial— Other <br /> Number of living units: Number of bedrooms M <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. ❑ 11 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 Properly Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI 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 /> i 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 applicant must call for all required inspections. Complete drawing on reverse side. 4 <br /> I <br /> Signed X_f , �+�+ Title: Date: <br /> MEhiVU5E ONLY .. <br /> t �3 1\� [oo Area <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> +, Additional Comments: <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> f Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMiT'NO. <br /> INFO h q c <br /> . E„13-zIREV.11nsV ao �a O. O f� �� <br /> EK t4-z9 <br />