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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)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> P 12 TT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby mede,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 IVA &�k City Lot Size/Acreage <br /> Owner's Name w`T 7 2 Address Phone <br /> Contractor Address,,,,_. License,No Phone. <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ( DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER D 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 /> Ll Industrial G Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fJ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing,.... Specifications <br /> I'1 Public., f Other i1 Delta Depth of Grout Seal Type of Grout <br /> ` I I`Irrioation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work pone D Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth <br /> ,Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK:' NEW INSTALLATION. REPAIR/ADDITION I I DESTRUCTION I i lNo septic system permitted if public sewer is <br /> ,/ available within 200 feet.) <br /> Installation will-serve: Residence -! Commercial_ Other <br /> Number o1 living units: 1 Number of bedrooms <br /> Character of soil to a depth of 3 lest: Water table depth ` <br /> SEPTIC TANK. d Type/Mfg" Capacit C� No. Compartments <br /> PKG. TREATMENT PLT, ❑ �-��7- Method of Disposal <br /> Distance to nearest: Well ��r Foundation Property Line U <br /> LEACHING LINE C` No. b Length of lines �T - Total length/size �r <br /> FILTER BED ❑ Distance to nearest: Well �` Foundation Property Line C? Cf <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PQNDS 0 <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 <br /> nd—rules and regulation+;of the San Joaquin County 1 <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 foltowing: "I certify that in the performance of the work for which this parmit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all uired inspections. Complete drawing on reverse side. <br /> Signed Title: Ccr�� =� Date: `� —� � <br /> FOfj•,DEPARTMENT USE ONLY- �� <br /> Application Accepted by Date Q Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Sam Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201 <br /> FEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY -DATE :iPERMiv NO. <br /> . EH 13.24(REV.I/K 5 <br /> EH 11-2111 <br />