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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 O BOX 2009, STOCKTON, CA 95201 <br /> ' PEEUXT EXPIRES I YEAR, FROM PATE-, IS, UED <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ' r <br /> Job Address� i � f() x s� <br /> City Lot Size/Acreage <br /> Owner's Name. .� ' <br /> y iii <br /> Address Phone <br /> Conte tractor I ��/ Address �r - _...�� - "v .• !14! <br /> �^icense No PhoneTYPE OF WELL/PUMP: NE WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 Out ofSerWellClPUMP INSTALLATION 0 $YSTEM REPAIR 0 OTHER p MonitoriWell 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S DISPOSAL FLO. `PROP:, LINE <br /> FOUNDATION AGRICUL7U WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 4 C UCTION SPECIFICATIONS <br /> n Industrial i <br /> © Open Bottom Cl Manteca I a. of Well Excavation Dia. of,1NelI•Casing i.�^-^-•� <br /> f Domestic/Private ❑ Grave! Pack- 0 Tracy Typ of Casing specification _ <br /> r. <br /> I'll Public Ci Other Cl Delta Dept of Grout Seal. Type of Grout. t f l <br /> I�I lrri anon "'"" '��"""""""�-"` <br /> g" „Approx. Depth !I Ea rn I Surfa a Seal Installed by <br /> Repair Work Done U Type of Pump ,H.P.� State Work bona r t I <br /> Well Destruction 0 Well Diameter' r f Sealing Maters 1 & Depth <br /> r Depth F'i11er,Material & Depth `y t <br /> TYPE OF SEPTIC WORK: NEW INSTAL ON I REPAIRlADDITION-! I DESTRUCTION I I (No septic system permitted ifspublic sewer is <br /> i"1111 <br /> ' availab`e within 200 feet.) <br /> Installation will serve: Residence� CornnierGal____ Other t � � � � <br /> f <br /> Number of living units: Number of bedrooms <br /> Character oft soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK' -•----O-Type/Mfg �6 ---- Capacity 0 No. Compartments <br /> PKG. TREATMENT PLT. C1 I0 Method of Disp al <br /> Distance to nearest: Well i <br /> . Foundation S Property Line <br /> i- <br /> LEACHING LINE I L.-No. & Length of lines Z of length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> t i <br /> SEEPAGE PITS . I ! Depth S Size PJumber <br /> SUMPS r r Ll s Distance to nearest: Well 0 6 <br /> Foundation <br /> DISPOSAL PONDS Property Line <br /> C] ��; -.' * � <br /> s <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 law:,,rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work forwhich this permit is issued, Ihland <br /> 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 f <br /> tion laws of California." i p Y Persons subject to-workman's compensa- <br /> TAe applicant ust call for squire inspections. Complete drawing on reverse side, <br /> r <br /> 00, <br /> f �+ r <br /> Signed Title: ° -r <br /> 5 Date: ! <br /> ` FOR DEPARTMENT USE ONLY I <br /> Application Accepted by / <br /> i Date '3d Area 7-11 li <br /> Pit or Grout Inspection by <br /> � Date Final Inspection by <br /> Additional Comments: <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 /> e FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> EH A-20 <br />'r"EH4 -20 <br />