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= APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> .I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> P IT 9M EMPIRES 1 YEAR FROM DAED <br /> F <br /> (Complete in Triplicate) <br /> li 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 Public Health Services. <br /> fr <br /> Cit�_�� Lot Size/Acreage <br /> Joh Address � _ - <br /> k / dCJ�G' Phone <br />} Owner's Nam Address <br /> i - �`-- 510 <br /> ddress Pv A r License Nae Phone <br /> Contract service Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of <br /> onitoring well <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ <br /> INE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUUMM <br /> PS r <br /> I <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> !7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing - <br /> C7 Domestic/Private ❑ Gravel Pack ❑ Type of Casing SpecificationsTracy ` <br /> L I'i Public l-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I tnigation __Approx. Depth -I l Eastern Surface Seal Installed by <br /> iState Work Done_ <br /> ' Repair Work Done ❑ Type of Pump H.P. <br /> f Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> Depth I I Filler Material & Depth p <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 5747 REPAIR/ADDITION i I DESTRUCTION I I !No septic system permitted if public sewer is �V <br /> available within 200 teet.l <br /> + lnstallation_willst3rve: Residence CommeFcial _3Other / <br /> f Number of h ing units: �.. Number of b Brooms <br /> F Character,�of soil to.a depth.of 3 feet:-- Water table depth <br /> SEPTIC TANK t ` ',13r Type/Mfg _ _ Capacity No. Compartments <br /> PKG. TREATMENT PLT-. ❑ Method of Disposal <br /> Distance to nearest: Wel! C540 Foundation /O Property Line, <br /> LEACHING LINE No. & Length of lines Ttat length/size <br /> I , <br /> FILTER BED Cl Distance nearest: Well Foundation ZQ Property Line <br /> Y <br /> SEEPAGE PITS 11 Depth Sire T G Nrmber <br /> SUMPS `d Distance to nearest: Well �-j — Foundation—/0- Property Line <br /> DISPOSAL PONDS ❑ :1 <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 /> - <br /> Home owner or licensed agent's signature certifies the folldwingi"I certify that in the`performance df the work for which This permit is issued, l 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 /> i The :pplicant t call for quir d inspections. Complete drawing on revers sickSignd X Title: ` ` Date: <br /> I y FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �� - -— Area <br /> lDate Final Inspection Y v � Dat-3- <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> i t <br /> Applicant - Return all copies to: 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 ASH RECEIVED BY, DATE PERM17 N0. <br /> ` INFO <br /> + £H 13-24{REV.118 5) <br /> EH:{2e <br />