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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)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> F <br /> PMWIT EXPIRES 1 YEAR FROM DATE SSUED <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 /> 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 City Lot Size/Acreage 'P <br /> Owner's Name Address Rhone 4, <br /> Contra CIO( <br /> dress Icense No. 1>14hone r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO ❑ t of service Well L1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C71 <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 ri <br /> N Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i <br /> s <br /> ! ('I Public I.]'Otherw-' '}�+ fl Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation ..Apar&--Depth ;I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump",j H-P. ---w State Work Done _ <br /> Well Destruction ❑ Well DiameteIr# } Sealing Material & Depth { <br /> I Depth Filler Material & Depth ` <br /> r <br /> TYPE-OF-SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is '6 <br /> A � it-ii;it-ii; available within 200 feet.I <br /> WnInstaf�llat� ff on will serve: Residence f Commercial_ Other i t <br /> Number of living units: ` Numberofbedrooms _ \1 <br /> Characterof soil to a depth.of 3 feet: Water table depth <br /> SEPTIC TANK. 0 'TypelMig ! Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1. Method of Disposal <br /> 7 [] <br /> Distance to nearest: Well1 ��F� Foundation Property Line. <br /> LEACHING LINE ❑ No. & Length of lines ' - Total length/size <br /> FILTER BED LI f Distance to nearest: Well l Foundation J IV Property, Line _ <br /> # F <br /> R <br /> SEEPAGE.PITS 11 Dept Number <br /> LI Distance to nearest: Well Mound ion Property Line <br /> DISPOSAL PONOS CI..a <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 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." ;Y <br /> The applicant sit f all req d inspections. Complete drawing o rse side. <br /> Signed Title: 1/1 -- Date: , <br /> F R DEPARTMENT USE ONLY f <br /> i Application Accepted by Date ! U 3 `Cj d Area �r <br /> Pit or Grout Inspection by Date Final Inspection by Date �D S <br />` Additional Comments: <br /> Applicant « Return all copies to: Ran Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> •1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> r FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'Np. 7 <br /> • EM 13-24(REV.I/K5) Igo_��_s k4 <br /> EH:b2a <br />