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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 F. HAZELTON AVE. , PHONE (209)468-3420 <br /> p 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FRO DATE <br /> (Complete in Triplicate) <br /> /ri tri <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 /> t dSD C W a o rt V r i!� IQ City C t3 Lot Size/Acreage u <br /> Job Address _ r� <br /> /1 ti Lot <br /> Owner's Name <br /> 1p f�4 Address ����� Q^ Lv ,Phone � ~ ,� <br /> Contractor <br /> Address _ License No. Phone <br /> TWE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well. <br /> PUMP INSTALLATION O— - " <br /> LL SYSTEM"REPAIR l�'�'" T OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK .,,,., ,— SEWER LINES DISPOSAL FLD. PROP. LINE <br /> - FOUNDATION- AGRICULTURE WELL OTHER L ` PITS/SUMPS � <br /> INTENDED USE TYPE OF WELL PROS AREA - CO3gRCTION SPECIFI TIONS _ U} <br /> Cl Industrial ❑ Open Bottom ❑ Manteca. _. DiaII Excavatio Dia. of Well Casing M. Q <br /> fa Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Cass Specifications <br /> i� <br /> I'i Public l-7 Other fl Delta Depth of Grou al Type of Grout <br /> v I } Irrigation —.Approx. Depth 1 I Eastern Sud ace S Install try <br /> Repair Work Done LJ Type of Pump H.P. tate Work Done _ <br /> 4 <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if-public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms y <br /> Character of soil to a depth of 3 feet: Water table depth <br />! SEPTIC TANK ❑ Type/Mfg Capacity ` " No. Compartments" <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Fo do Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/sjze <br /> FILTER BED C7 Distance to nearest: Well oundatia Property line <br /> r SEEPAGE PITS 11 DepthSize Number <br /> t SUMPS l Distance to nearest: Well Foundation . -- Property Line <br /> DISPOSAL PONDS © <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 /> �I 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, ! shall not <br /> employ any person in such manner as to become subject to workman's compensation lawsfof California." Contractor's hiring or sub-contracting signature <br /> certifies the following: '1 certify that in the performance of the work for which this permit 1 lssuad, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> l The applicant mu t i&A for all req it inspections. Complete drawing on reverse side. <br /> `! Title: . w r\{f` Date: <br /> Signed X <br /> a <br /> FOR DEPARTMENT USE ONLY �] <br /> Application Accepted by Date Area v <br /> Pit or Grout Inspection by Date Finel Inspection by Date <br /> Additional Comments: 1/, <br /> Applicant - Return all copies to: San Joaquin County Public Health 5 `/ i� V, 7/V <br /> Services, -Envi-ronmental Health Permit[Services <br /> 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA `95201 !� 'P pain I <br /> FEEMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMi7 NO. 1jD l 7 <br /> INFO <br /> . EH13-241AEV.%/K5f <br /> EH 14-26 `C <br />