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N <br /> APPLICATION FOR PERMIT <br /> ;SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> r G 1601 E. HAZELTON AVE. , PHONE {209}468--3420 <br /> y P O BOX 2009, STOCKTON, CA 95201 <br /> J <br /> ?ERMiT E_ %FIRES i YEAR FROM DATE $XIED <br /> (Complete in Triplicate) <br /> i <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r� f I— City Lot Size/Acreage �f� <br /> Job Address <br /> ` 1 <br /> ` Owner's Name � f /' ddress Phone <br /> Contractor 1 f E` U `Sl�'L/� v4 License Nov .—Phone <br /> AddressLE UeA <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION XOut of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El Monitoring Well ❑ <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> I FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> F INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ' nIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C.1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public I:1 Other } fl Delta Depth of Grout Seal Type of Grout <br /> I Irrigation _..Approx. Depth t I Eastern Surface Seal Installed by <br /> I Repair Work Done L] Type of Pump H.P. State Work Done <br /> + <br /> Waif Destruction © Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION X INo septic system permitted if public sewer is i <br /> available within 200 feet.) <br /> j installation will serve: Residence' Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _r*A 6i Water table depth <br /> SEPTIC TANK ® Type/Mfg Capacity PdodA No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> € Distance to nearest: Well /00 Foundation Property Line <br /> I ' <br /> LEACHING LINE Cl No. & Length of lines l bt __ Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 1 ) Depth Size Number <br /> I SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ , <br /> 1 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: "l 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 signatures <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." a <br /> �? 4 <br /> The applicant must call for allpequirsV 'nspections. Complete drawing on reverse side. <br /> Az---o <br /> •- T <br /> 'Signed X Title: Sjh l�f f'dh /L p Lr Az---o f i t•.c%l h t&rDate: 0 <br /> O EPARTMENT USE ONLY <br /> Application Accepted by Dat - Area 0 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> i <br /> Additional Comments: <br /> Applicant Return all copies to: San Joaquin Count blic Health <br /> Services, Env1r.onii'6ntal Health Permit/Services <br /> 1601 E. Hazeon Ave., P 0 Box 2009, Stockton, CA 95201 <br /> t FEEAMOUNT DUE OUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> I INF?7 CASH <br /> [ Q� <br /> a EH 13-24(REV.I/n 51 —1 <br /> EH 14.26 <br />