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r_ a <br /> 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 O BOX 2009, STOCKTON, CA,95201 <br /> pg Ull EXPIRES 1 YEAR FROM DATE SSUPD_ <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. j <br /> Job Address <br /> L City +� ry Lot Size/Acreage <br /> KLZe11Z O J�Address 3 '"9 Phone J <br /> Owner's Name ...., <br /> Contractor os r' License No..��^ Phone <br /> TYPE OF WELL/PUMP:. <br /> NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ Out of Service Well CI <br /> _ - Monitoring well L3 <br /> PUMP INSTALLATION ❑ -..—�. SYSTEM REPAIR $f OTHER ❑ <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 I <br /> Dia. of Well Excavation Dia. of Well Casing <br /> F1 Industrial ❑ Open Bottom D Manteca <br /> FI Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'} Public -1 Other n Delta Depth of Grout Seal Type of Grout <br /> Irrigation _.Apprax. Depth I I Eastern Surface Seal Installed by _ <br /> i Repair Work Done U Type of Pump fu2�N-� H.P. &45> State Work Rona l , <br /> Sealing Material Depth 1� ~ cc12 X14/ <br /> Well Destruction El Well Diameter � <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITION I 1 DESTRUCTION l I lNo septic system permitted if public sewer is <br /> r 44 f available within 200 feet,l <br /> 3 <br /> installation will serve: Residence' Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to-a depth of-3-feet:— ---- -Water-table depth ( , <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> PKC. TREATMENT PLT. ❑ i. -' Method of Disposal j <br /> Distance to nearest: Well F1 lob. <br /> oundation Property Line <br /> 1 <br /> LEACHING LINE D No. & Length of lines ' Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line r <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Li Distance to nearest: Well Foundation Property Line f <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquinicounty 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." <br /> The applicantfor all required inspections. Complete drawing o verse side. <br /> Signed X Title: Date: - <br /> OR DEPARTMENT USE ONLY Gj <br /> Application Accepted by Date_ r Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health `t <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO (�Q <br /> . EHi3-2.4 61 <br /> EH i4-2a k <br />