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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC. H.EALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES1 YEAR FROM DATE ISSU <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 /> l <br /> Joaquin County Public Health Services. 4 G <br /> l ter... <br /> Job Address City n Lot Size/Acreage <br /> Owner's Name C j AddressPhone <br /> f <br /> Contractor Address f ob VH License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION r.❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> C� FOUNDATION AGRICULTURE WELL OTHE14 WELL PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 Cl Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public Ti Other R Delta Depth of Grout Seal Type of Grout <br /> w I i Irrigation Approx. Depth I #Eastern Surface Seal Installed by, <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Filler Material & Depth <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sower is <br /> / available within 200 feat.) <br /> 111. Installation will serve: Residence'! Commercial Other <br /> � Number of living uniti: ---. Nu'm' ber of bedroom <br /> I. <br /> Character of soil to a-deptli of 3 feet: Water table depth <br /> SEPTIC TANK #Type/Mfg Capacity- No. Companments <br /> PKG. TREATMENT MLT. ❑ ' I Method of Disposal <br /> Distance to nearest: well Q_ Foundation - Property Line <br /> LEACHING LINE Leo. & Length of lines , n.'`....-... ��c�^T Total length/size_ c�7 <br /> F. Ot- <br /> FILTER BED ❑ Distance to nearest: Well Foundation__ Z__ _ Property Line - <br /> F1SEEPAGE PITS Depth rr}-r Size t� Number <br /> SUMPS Distance to nearest: Well�— Foundation L ,?Sr _ Property Line _�_�— <br /> DISPOSAL PONDS ❑ <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 /> F� 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." Contractors 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 /> II The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X if ALI Title: Date: <br /> 9 f FOR DEPARTMENT USE ONLY, <br /> t �— <br /> Application Accepted by Date d Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health r(* <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE /AMOUNT REMITTED CASH CK RECEIVED 13Y l GATE PnERM7IT'NO.. <br /> t <br /> EH <br /> CH 13-24(REV.t/As l <br />