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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> I <br /> t PERMIT EXPIRES 1 YEAR FROM DACE ISSUED <br /> (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 /> I 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 /> Job Address I ld 7 L flirt S City_Oin Lot Size/Acreage <br /> Owner's'Name •1 O ,X w w i S Address ! c1� Phone 4 <br /> Contractor L Address -S k" 'r' Y License No. Phone <br />{ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L3 OTHER ❑ Monitoring Well ❑ <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public El Other + n Delta Depth of Grout Seal Type of Grout \ <br /> 1 I Irrigation _..ApproK, Depth l I Eastern Surface Seal installed by <br /> 1 Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth t Filler Material & Depth ! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAID/ADDITION i l DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence"� Commercial— Other <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 fef Water table depth , <br /> SEPTIC TANK. c, Type/ y _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ �!� – 4 LM 600,r Method of Disposal <br /> wDistance{t�t Gt � mnIhav&-eyifed"K#1 Property Line <br /> Y <br /> " LEACHING LINE CI No. & Le4 I ging co ^N Total longth/size <br /> ,,I L�� t�t, r,' <br /> FILTER BED ❑ Distance t' ti&tvir( wim;_:.�.Gi1..-I_iGattclur�lWsinn Property Line <br /> SEEPAGE PITS 11 Depth + Size f Number <br /> SUMPS LI Distance'lo nearest: Well Foundation Property Line M <br /> DISPOSAL PONDS ❑ � , <br /> I I hereby certify that I have prepared this1appiication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> i 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 became 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 compense- <br /> tion laws of California." <br /> The applic nt must cafor all rewired inspections. Complete drawing on reverse side. <br /> w <br /> Signed Title: 0f4r• 1/I t`_�" Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by , Date 1 Arse <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: ' <br /> I Applicant – Return all copies to:1 San Joaquin County Public Health <br /> ;] Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IF <br /> Q AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMW N0. <br /> . EH13.24CREV.rin5l X500 IOp / > 12-1EN 14.29 � 1,­d <br /> 4 <br />