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T till:' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION . <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 1 E%PRES -1 YEAR FR M D T <br /> 1 (Complete in Triplicate) <br /> 5' <br /> Application is hereby made Sats Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in,'cotrpliance5vith.San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /� �t// <br /> c- � /- City der Lot Size/Acreage <br /> Job Address /�QQ <br /> Owner's Name Address <br /> �` <br /> J ����Address I Vp License No. Phone <br /> Contractor /Y� of service i�,—L <br /> TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR )l OTHER ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _r <br /> I� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n industrial 0 O Bottom ❑ Manteca Dia. of Well Excavation <br /> g <br /> Type of Casing Specifications <br /> ['ADomestic/Private ❑ Gravel Pack C3 Tracy Type of Grout <br /> I'I Public 1-1Otherf (-I Delta Depth of Grout Seal <br /> I i Irrigation Approx�Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diametei <br /> Sealing Material & Depth <br /> Depth f. Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR JADDITION l I DESTRUCTION I I [No septic sy t m permitted if public sewer is <br /> eet,I <br /> Installation will serve: Residence i Commercial_ Other PAYMENT <br /> Number of living units: Number of bedrooms IPAY� N7 <br /> Character of soil to a depth of 3 feel j <br /> SEPTIC TANK ❑ Type/Mfg Capacity n�l+ + sl <br /> PKG. TREATMENT PLT. ❑ 4 U dthotl Y <br /> Distance to nearest: Well Foundation_ XQLT°1SER G, S <br /> LEACHING LINE D No. & Length of lines <br /> TolgINm1�?111 AL HEAL <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that i have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state iaws, 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 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 t call fo all r red in cti s. Co lets drawing on reverse side. <br /> Signed X t r Title: �r�17 — Date: <br /> F DEPA U O <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection by f Date Final Inspection bDat�� <br /> Additional Comments: <br /> 'l <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Havironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> I' <br /> FEE AMOUNT DU AMOUNT REMITTED RECEIVED BY O 7E PERMIT'NO. <br /> lNFO <br /> S w <br /> : EH 13-24 IAEV.1/M` <br /> EH 14.26 <br />