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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 /> PERMIT EXPIRES 1 YEAR FROM <br /> (Complete in Triplicate) <br /> F <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. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> �lp F �, c!� City Lot Site/Acreage �6�c <br /> Owner's NameL 6 -�� c°r� Address ,n Phone <br /> Contractor ''_ . re/GC �Address P6 � � /l�r�c' _License No. Fmone S- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of service Well ❑ <br /> - PUMP INSTALLATION ❑—_ - SYSTEM REPAIR Q 'OTHER ❑ Monitoring.xel2....0_ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> -FOUNDATION­ - AGRICULTURE WELL - ,OTHER.WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing <br /> f.I Domestic/Private ❑ Gravel Pack #LJ Tracy Type of Casing Specifications <br /> l'I Public - C1 Other -Cl Delta Depth of Grout Seal Type of'Groutr' <br /> I ! Irrigation —Approx. Depth Cl Eastern Surface Seal Installed by - �I <br /> Repair Work Done U _ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth �. <br /> 'f Depth `Filler.Idaterit►1`t-bepth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION tA REPAIR/ADDITION 1 1 DESTRUCTION l I (No septic system permitted if public sewer is \ <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other'"" <br /> r <br /> Number o1 Gving units: 4— Number of bedrooms <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg t Capacity No. Compartments <br /> PKG. TREATMENT PLT•.❑ �' � <br /> Distance to nearest: Well Foundation oe -_ Method of Disposa0e(0Property.Line O F <br /> LEACHING LINE Cl No. & Le6gth of)ales _ Total longth/size - <br /> FILTER BED f-J Distance to nearest: Well Foundation F f Property Line lD <br /> SEEPAGE PITS 11 Depth Size Number _ { <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS n <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance.wiih 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, 1 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." I <br /> The applicant must Gall for alt required inspections. Complete drawing on reverse side. <br /> i <br /> l Signed X Title: ( - .d Date: ��_�0 <br /> l <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date ac 3 Area <br /> Pit or Grout inspection by Date Final Inspection by ate <br /> J <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Raselton Ave„ P 0 Box 2009„Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH 3-24 IREV.r/wsl A0 b <br /> EH i4•?d <br />