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APPLI CAIT1 n, OR PERM I T <br /> SAN JOAQUIN COUNTY-'PUBLIC HEALTH SERVICES <br /> R EC"EI <br /> (ENVIRONMENTAL HEALTH DIVISION SSL 9 1991 <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS9(3ED <br /> PERMIT/SE VICES <br /> I� (Complete in Triplicate) <br /> Application is hereby made,to San,Joaquin'County for a permit to construct and/or install the vork herein described. This <br /> application Is 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. Wy <br /> Job Address Lot Size/Acreage <br /> w � V ~ <br /> Owner's N4A ,.ss Phone <br /> �Cn Ett6r `�' '""� ' 'v' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTn- DESTRUCTION LI Out of Service Well C) <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well €� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �n I .ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r <br /> t�gmestic/Private L) Gravel Pack. ❑ Tracy Type of Casing Specifications <br /> I'I Public' [:1 Other j 1-1 Delta Depth of Grout Seal Type df Grout <br /> I I Irrigation Approx.;Depth E stern Surface Seal Installed by <br /> Purr p <br /> Repair Work Done D Type of PuH.P. State Work Don <br /> Well Destruction 0 Well Diameter Sealing Material & Depth 9v <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 lNo septic system permitted if public sewer is <br /> P available within 200 feet.) <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, 0 Method of Disposal <br /> Distance to nearest: Well Foundation=K Property Line <br /> LEACHING LINETotal length/size <br /> ❑ No: & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well 4 Foundation Property Line <br /> i` � wa i <br /> SEEPAGE PITS I ) ".Depth ,~ -Si:e4 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 countyi ordinances, state laws, and <br /> rules and regulations of the San Joaquin poun <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which%his'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 hiringlor 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 appli cnu t call inspections, Complete drawing on rever ids. <br /> Si ed Titl Date t ( �, <br /> i <br /> FOR PARTMENT USE ONLY <br /> Application Accepted by Date < a +Area <br /> Pit or Grout Inspection by Date Final Inspection by Date [ <br /> Additional Comments: <br /> Applicant - Return all copies tri: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED �K H RECEIVED BY DATE PERMIT'N0. <br /> 1 O 1 <br /> . EM13-24 Mv.tins! ��� <br /> EH 114.25 JJ 11 <br />