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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ALTH DIVISION <br /> 1601 E HAZELTOENVIRONMENTAL E.,PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DA E ED <br /> (Complete in Triplicate) <br /> i Application is hereby made to San Joaquin County for a <br /> work <br /> application is made in compliance with San Joaquin countyrmit ordinancenstruct No. 549 andand/o1862atall and theeRules andein Regulationsdof Sans <br /> Joaquin County Public Health Services. <br /> Job Address k City Lot Size/Acreage <br /> t. . <br /> Owner's Name '� .` <br /> Address,' Phone <br /> - i -- II <br /> Contractor <br /> ense No. Phone <br /> TYPE OF WELL/PUMP:"--•NEW WELL 0-W LL"REPLA'CEIv1ENT P- DESTRUCTION ❑ Out of Service Well ❑ <br /> 24 <br /> PUMP INSTALLATION O SYSTEM REPAIR El OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANKCJ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA` %CONSTRUCTION_SPECIFICATIONS <br /> C-7 Industrial - ❑ Open Bottom ❑ Manteca Dia- of Well Excavation <br /> Cl Domestic/Private 1 0 Gravel Pack C] Trac Dia. of Well Casing <br /> Y Type of Casing Specifications <br /> k f'! Public - la Other • 11 Delta, Depth of Grout Seal <br /> t I I Irrigation A Type,of Grout <br /> -- Approx. Depth 1 1 Eastern Surface Seal Installed by. <br /> Repair Work Done ❑ Type of Pump H P T. <br /> State Work Done <br /> Well Destruction ❑ Wel! Diameter Sealing Material & Depthy <br /> f.. Depth Filler Material & <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I'1 REPAI ADDITION.I DESTRUCTION I I tMo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial. Others s <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> 1� SEPTIC TANK r Water table depth <br /> ❑ <br /> 1 Type/Mfg Capacity ' No. Compartments <br /> PKG. TREATMENT PLT, ❑ <br /> t Method of Disposal 0 <br /> { Distance to nearest: Well x,;{ <br /> Fouridation Property Line <br /> 'LEACHING LINE t Cl No. & Length of lines / <br /> „a FILTER BED ❑ Distance to nearest: Well Foundation, <br /> Total length/size <br /> r Property Line <br /> ,SEEPAGE PIT DepthSize w ✓ _ <br /> ,SUMPS LI Number <br /> I Distance to nearest: Well Foundation; <br /> �DISPOSAL PONDS ? C) Property Lithe `( <br /> ertify that l have prepared this application and that the work wilt be done in ac <br /> 11 hereby ccordance with San Joaquin county ordiriances, state laws, and <br /> rules and regulations-of the San Joaquin County <br /> ¢Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, t shall not <br /> employ any parson in such manner as to become subject to workman's compensation lawi ' California," Contractor's hiring or sub-contracting sigriatute <br /> icertiTies the fallowing: "I certify that in the performance of the work for which this permit is issued <br /> tion laws of California." ,pe tions. Co plat rowing orre e��si , 1 shall employ persons subject to:workman's compensa <br /> h� <br /> fhe applicant mu cal r a uire i I t <br /> i � { <br /> Signed XTitle: { ,. 71 <br /> Date: <br /> FO . <br /> _ ENT USE ONLY <br /> !Application Accepted by '"`Date' <br /> ,Area <br /> Pit or Grout Inspection by ate Final Inspection by_ <br /> Date D ; <br /> 'A 'net Comments: p` I <br /> i <br /> Appli\t�- Return 811 copies to: San Joaquin County Public Health °�Cr� <br /> tServices, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 E <br /> FEE' NT DUE AMOUNT REMITTEDCK <br /> INFO CASH RECEIVED BY DATE, PEltM1T'N0. <br />. EH 13-25(REV.tiN51 }•� ���� <br /> EH 41.25 C- Cks ^. <br />