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APPLICATION FOR PERMIT � T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BO&' 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FRQM DAIE 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 /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 <br /> Job AddressWQoG��7rli?� C°t\ <br /> ,..��ity /"� 0 Lot Size/Acreage <br /> Owner's Name . Al Address ZS � f"�°� Phone + 4C-S- <br /> Contractor �� Address License No. Phone_ <br /> .TYPE.OF WELL/PUMP: NEW WELL ❑ t WELL REPLACEMENT:- C_l DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP-INSTALLATION-- Y_,_ _,_._ SYSTEM REPAIR - - -OTHER ❑-- ---Moni.toring...Well.,,:u_, <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 Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing Specifications <br /> V] Public 1-1 Other n Delta Depth of Grout Seal Type-of Grout <br /> Irrigation w_Approx. Depth I I Eastern Surface Seal Instailed by <br /> Repair Work poneI U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth C� C.— <br /> Depth Filler Material & Depth Ciwtr x <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [ I DESTRUCTION I l lNo 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 _ <br /> Character of soil io a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity. No. Compartments <br /> PKG. TREATMENT PLT. ❑ q <br /> Method of Disposal <br /> Dlstance'to rise►est:""""Well ^" Foundation--L �^"T"� p-operty iEr3d—'r" <br /> LEACHING LINE Cl No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line r <br /> E <br /> SEEPAGE PITS I 11 Depthize Number <br /> SUMPS Lf Distance to nearest: Well Foundation_ Property Line <br /> DISPOSAL PONDS. ❑ <br /> I hereby certify that:1 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 11 <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, 1 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 iaws'of California." -_ ,o perso _ _ <br /> The applicant must call for all req i spections. Complete drawing on reverse side. <br /> Signed X � , � Title: Date: <br /> ! FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �- Area <br /> r <br /> Pit or Groot inspection by Date Final Inspection b <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> .. . . . ..,Services....Environmental,Health Permit/Services ----- - <br /> Q <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> YFEEAMOUNT DUE AMOUNT REMITTED -CK RECEIVED BY DATE PERMR'NO. <br /> CASHEH13-24IREV.t1HSIj/b ��^�EH 14-26F•-� SVS `t�^O'7�•G� C_L./ <br />