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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 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROG DA E 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 1862.and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ` L i <br /> / City to !sy Lot Size/Acreage Lld._� <br /> Owner's Name ac, /IJJ+ Address <br /> Phone <br /> Contractor W-7 Address SC License No, O Phone��� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> ,,,,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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' ' C]-Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Y r <br /> Il Public t'3 Other n Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation ,Approx, Depth I I Eastern Surface Seal Installed by rr • <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction 0 Well Diameter Sealing 4Uterial 'a.Depth <br /> Depth Piller Material 8 Depth' <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION I I REPAIR/ADDITION DE RUCTION I i (No septic system permitted if public sewer is <br /> >available within'200 feet.) <br /> Installation will serve: Residence` Commercial— Other "} <br /> Numbec.af living units: Number-nf..bedroSms <_ <br /> Character of soil to a depth of 3 feet �— <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg" Capacity'-.-- No. Compartments <br /> PKG. TREATMENT PLT.-El Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size_ <br /> r <br /> FILTER BED C) Distance to nearest: Well / Foundation ) Property Line^ f <br /> SEEPAGE PITS l I Depth Sixe__�� Number 2— <br /> SUMPS <br /> DISPOSAL I PONDS Ll <br /> SUMPSLI Distance to nearest: Well��� � <br /> Foundation,... property Line�/=�--- <br /> DfSPOSAL POND5: ❑ <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 fallowing:"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 applicant must c r all rV4_ui­reA in actions. Co plate drawing on reverse side. <br /> Signed X Title: it J <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ rn V Date C-,/ b —C1 I <br /> Area <br /> n �� <br /> Pit Grout Inspection bq�Z�nh 0�� � Date � ` Final Inspection by � -� Date C-f'! L <br /> Additional Comments.- <br /> Applicant <br /> omments:Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 9520.1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO h CASH �RECEIVED <br /> (} BY DATE..,. PERMIT'NO, <br /> EHA-211REV.iinSr pc� V© 3r�/ �, .:..__,l� <br /> EH 71-2a e <br />