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1 <br /> W ��r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION aU 9 19120 <br /> 1601 E. HAZELTON AVE. , PHONE (200468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ZNViRONMENTAL HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU92 PERMIT/SERVICES <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�Pjublic Health Services. <br /> �'wv > ,f <br /> Job Address L S�� `�7 Cit l�-� Lot Size/Acreage <br /> f <br /> Owner's Nam Addres Phone 'r <br /> ont t ss erase No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER D Monitoring Well <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 <br /> N Industrial ❑ Open Bottom ❑ Manteca s Dia-of Well Excavation Dia. of Well Casing <br /> estic/Private ❑ Gravel Pack ❑ Tracy 9 Type of Casing Specifications <br /> i'I Public fa Other fl Delta Depth of Grout Seal Type of Grout <br /> i I irrigation — Approx. Dep h i as rn ! Surf a Seal Installed by <br /> Repair Work Done ❑ Type of Pum H.P. _ State Work Done <br /> Well Destruction ❑ Well Diameter Well Material 6 Depth <br /> Depth FilleriMaterial & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is —r <br /> available within 200 feet-1 <br /> installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <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 \� f i Total length/size <br /> FILTER BED ❑ Distance'to nearest: Well. Foundation Property Line <br /> 'J <br /> SEEPAGE PITS" T - 11 Depth Size` _ Number <br /> SUMPS Ll Distance o nearest: ,,,Well Foundation Property Line <br /> DISPOSAL PONDS - O <br />_ k " <br /> I hereby certify that I have prepared this application and that the worl� 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 workmen's compensation laws of California."Contractor's hiring of 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 applicantt call for required inspections. Complete drawin on rev se side. <br /> Signed _ Title,: Date: <br /> i <br /> FOR DEPARTMENT USE ONL ^7 p <br /> Application Accepted by h�7- _f Date <� 3��l� ^ Area e! <br /> Pit or Grout Inspection by Date Final Inspection by ,7'2� % 6 <br /> Additional Comments- <br /> Applicant <br /> omments: _ <br /> A licant �- Return all copies to: San J I <br /> pp p Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH v CK RECEIVE) BY DATE PERMIT'NO, <br /> . EH 13-24(REV.1/951 �(( AMIW- /Grfq p �J�75 <br /> EH:1.20 -7� w��.iii+++w���ii+++���++++ l <br />