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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOIL 2009, STOCKTON, CA 95201 Y <br /> RtlsiTT F.$PIRES 1 YEAR FROM DAT MW-ED <br /> (Complete in Triplicate) <br /> r a permit to vork <br /> in <br /> �e•liancn Joaquvith inncouaqula County OrdinancenNoruct 5G9asndo18628tall and theeAules andeRegulationsdof Sane <br /> Application is hereby <br /> onty <br /> application is trade 1 coup <br /> .Joaquin County Public Health Services. t <br /> City "Lot Size/Acreage <br /> Job Address ']" <br /> Phone <br /> Owner's Name _ <br /> Address � <br /> Address License No._phone_ <br /> Contractor `"'' DESTRUCTION ❑ Out of service Well ❑ <br /> TYPE OF'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ____�.•-- <br /> PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> Dia. of Well Excavation <br /> F] Industrial ❑ Open Bottom ❑ Manteca Type of Casing Specifications <br /> EI Domestic/Private ❑ Gravel Pack El Tracy <br /> Type of Grout <br /> I'1 Public 1=1 Other C1 Delta Depth of Grout Seal <br /> I tfogation —Approx. Depth I I Eastern Surface Seal Installed by <br /> of Pump H.P. State Work Done_ <br /> Repair Work Done 0 Type sealing Material Depth i <br /> Well Destruction ❑ Well Diameter Filler Material 5 Depth <br /> i Depth ; <br /> stem perm <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l DESTRUCTION I 1 arvailableo se �wthin 200 feetr.]ed if public sewer is <br /> s <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> 4 Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity-- <br /> Method of Disposal <br /> j PKG. TREATMENT PLT. ❑ <br /> f Distance to nearest: Well Foundation Property Line <br /> y <br /> ize <br /> Total length/s <br /> LEACHING LINE L�1 No. & Length of lines ,f <br /> F undatian Property Line <br /> FILTER BED F1 Distance t arest; Well <br /> SEEPAGE PITS 1 1 Depth Size Number <br /> 5 SUMPS U Distance to nearest: Well Foundation Property Lina <br /> I DISPOSAL PONDS ❑ <br /> I hereby certify that l 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 /> performance <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perorof the work for which this permit is issued, I shah not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring o+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 applicant must call for all required ins ctions. Complete drawing on reverse side. <br /> _ j <br /> Signed X r Title: _ �` Date: <br /> g <br /> FO EPART T USE ONLY <br /> Date � d A a <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Dat 4' <br /> SAdditional Comments: <br /> t Applicant - Return all copies to: Ban Joaquin County Public Health <br /> i Services, Environmental Health Permit/Services <br /> I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYjDAjTEPERMIT'NO. <br /> INFOEH 1344(REV.t/N5) e <br /> EH 14.25 <br />