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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ' S ' <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> U72RIiTT EXPIRES 1 YEAR FROM HATE <br /> (Complete in Triplicate) <br /> i 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 /> i Joaquin County Public Health Services. <br /> 5City ±Oxk4fp'1Lot Size/Acreage <br /> Job Address �L � ll__ <br /> Owner's Name 't Address <br /> 3� 5 .01-0 Qvq s{CJ(���7n Phone <br /> Contraclor <br /> Yll1�r'n Address ���3 `�' rpr s� ' License No, 3�5 Phone 31'J� 3 <br /> Out of Service We11 ❑ <br /> -"TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Monitoring Well <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C.l Domestic/Private Gl Gravel Pack 1-1_Tracy ' `Type of Casing Specifications <br /> I'1 Public 1-1Other 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by + <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing laterial 8 Depth <br /> i <br /> Depth -.� Filler Material b Depth permTYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIRIADDITION l I DESTRUCTION availaeptic thin system }emitted if public sewer is <br /> r 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 O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> G <br /> k LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> h FILTER BED ❑ Distance Ito nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth I Size Number <br /> SUMPS L: Distance,to nearest: Well Foundation A- - Property Line <br /> i DISPOSAL PONDS ❑ I <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 /> 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." C <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 /> r The applicant must call for a I required inspections. Complete drawing on reverse side. <br /> �z <br /> Signed X -- <br /> Title: Date: <br /> F DEPARTMENT USE ONLY <br /> IArea <br /> Application Accepted by Date / <br /> Pit or Grout inspection by I Date Final Inspection by Data / <br /> a Additional Comments: I <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> } Services, Environmental Health Permit/Services <br /> If 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95?01 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 8 CASH RECEIVED BY DATE PERMIT'N0. <br /> INFO nn 7/.;: <br /> /7 <br /> ' . EH 13.24[REV.1)8 5) pry 7 , t7 t� t ^�t-� ( !/ �"� <br /> EH 1426 <br />