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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 O BOX 2009, STOCKTON, CA 95201 ` <br /> }r I< PMIT-EXPIRES 1 YEAR FROM DATE ISSUM <br /> r (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 Public Health Services. t <br /> Job Address / ! City '- Lot Size/Acreage <br /> dr ss nerss c� .�. G . Phone � a-3/ ; <br /> �( Ow 's Name <br /> /\ \ r� �/G r / License No. Phone <br /> Contractor Address <br /> 7YPE OF WELL/PU NEW WELL C1WELL REPLACEMENT C 1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> f_-1 Industrial C3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> [-I Domestic/Private ❑ Gravel Pack- . 0 Tracy Type of Casing Specifications <br /> F] Public 1-7 Other 1 n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth l t Eastern Surface Sedl Installed by <br /> Repair Work Done 0 Type of Pump H..P. --=- - State Work Done...:.. <br /> Well Destruction ❑ We11 Diameter Sealing Material ii Depth <br /> Depth <br /> "I Filler Material 6 Depth <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTIONKINo septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> I 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 1 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest:+ Well Foundation Property Line <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size_ <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 4 <br /> SEEPAGE PITS 11 Depth ! Size Number <br /> SUMPS Ll Distance to nearest: Well f Foundation Property Line <br /> ! DISPOSAL PONDS C) <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 /> 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 of subcontracting 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 must call for plj re ui s mplete drawing onreverse side. <br /> Signed X Title: Date: <br /> FO E -ONLY. l u ^� p <br /> ° Application Accepted by Date y L V Area 11 �— <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> ti Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 05201 <br /> FE AMOUNT DUE AMOUNT REMITTED ASH R IVSD t3 DATE PERMIT'NO. <br /> I - <br /> . EH 13-N IREV.i/K51 -11s'l <br /> EH 3.25 ✓✓✓ <br /> t <br />