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APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH. DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)4683420 <br /> P 0 BOX 2009, STOCKTON, CA 95201'; <br /> WIT EXP RES i YEAR FROM DA E <br /> Ep 7�I <br /> (Complete in Triplicate) <br /> Application ihereby made to San Joaquin County for a permit <br /> application iss made in compliance with Sato construct and/or install.-the'work herein described. This <br /> Joaquin County Public Health Services. n oaquin County Ordi ance No. 549 and 1862 abd the RuleB �and Regulations of San <br /> S ,� <br /> Job Address 9 .� . <br /> City Lot Size/Acreage <br /> Owner's Name RlgWdress <br /> Phon <br /> 'Contractor <br /> Address <br /> TYPE OF WELL/PUMP; NEW WEL License No3&2P--2 Phon <br /> WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR C1 i; OTHER ❑ Monitoring Well <br /> M r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ❑ <br /> DISPOSAL FLD:_ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL "PITS/sumps�� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial �--— I <br /> ❑ Open Bortom ❑ Manteca Dia. of Well Excav tion <br /> C� Domestic/Private Gravel Pack s � pia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> Public C7 Other f� Delta Specification <br /> Depth a(Grout Seal ! <br /> 1 I irrigation Type of Grou <br /> 1'�,. Approx. Depth V--Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump — <br /> H.A. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DE5IRUCTION I I (No septic stem <br /> P Y Permitted if public sewer is (Y1 <br /> Installation will serve: ResidenceCommercial Other available within 200 feet.) \' <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg "''Water table depth <br /> (� r <br /> PKG. TREATMENT PLT. ❑ Capacity ,No. Compartments `� f <br /> Distance to nee st: Well Method of Disposal j <br /> Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines ' <br /> Total length/size <br /> FILTER BED <br /> CI Distance to nearest: Well Foundation _ Property Line � <br /> SEEPAGE PITS I i Depth <br /> Site_ Number <br /> SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation_ Property Li' <br /> ns <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, arty (/1 <br /> rules and regulations of the San Joaquin County i <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 following: "I certify that in the performance of the work for which this permit is issued, I shall em to <br /> tion laws of Ca!'oinia." P <br /> P y persons subject to workman's compensa- <br /> The applic s II f r all re ed in ctions. Complete drawing on rse side <br /> Signed _ <br /> Title: Date: _ " <br /> F -MENT USE ONLY <br /> Application Accepted by <br /> Date [ u Area <br /> Pit or rou Inspection by <br /> Data��� Final inspection b -� r <br /> Additional Comments: <br /> Date --2,r <br /> 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 95201 l <br /> FEE AMOUNT DUE AMOUNT REMITTED CK If <br /> INFO CASH RECEIVED BY PATEI! <br /> PERMIT N0. <br /> EH A-2A IREV.I/K 51 <br /> EH Q I p ` <br /> I <br />