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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 SOX 2009, STOCKTON, CA 95207E <br /> EMIT EXPIRES 1 YEAR FRPM DA Ts ISSUED <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 /> I Joaquin County Public Health Services. <br /> Job Address Cit (� <br /> y 1 Lot Size/Acreage <br /> Owner's Name f} � Address t Phone--%Lrfr I <br /> 'Contractor Address <br /> License No, Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> CDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f -DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q <br /> L7 Industrial C50pen Bottom ❑ Manteca Dia. of Well Excavation Dia'-6f Well Casing <br /> ' - r_d Domestic/.Private -❑ Gravel-Pack- ❑ Tracy Type of Casing Specifications <br /> I"7 Public �u fa Other = w t 1 Delta Yy Depth of Grout Seal „Type of.Gro <br /> fl Irrigation A ;P — r- <br /> pprox. Depth 1 ) Eastern Surface Seal Installed by <br /> r Repair Work Done 0 Type of Pump H.P. State Work Done, <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> i <br /> Depth t Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/AD�ITION I ! DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I Installation will serve: Residence_—` Commercial Other <br /> Number of living units: Number of bedrooms 1 R� <br /> Character of soil to a depth of 3 feet: Water table depot I Vv <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br />+ PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br />` LEACHING LINE Cl No. & length of lines 1 <br /> C Total length/siz ;,e <br /> FILTER BED 1-1 Distance to nearest: Well Foundation Property Line \ <br /> SEEPAGE PITS 11 Depth I Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line i <br /> DISPOSAL PONDS ❑ s <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 /> Home owner or licensed agent's signature cenifies 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California.' I <br /> The applica ust call fo all re i pections. Complete drawing on reverse side. <br /> Signed <br /> Title: <br /> Date: <br /> FCkR DEPARTMENT USE ONLY 4 A <br /> Application Accepted by Data Areaj — �-- <br /> Pit or Grout Inspection by Date Final Inspection by i <br /> Date�- <br /> Additional Comments: l F -�7 <br /> Applicant - Return all copies to: San Joaquin County Public Health F <br /> -Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 x 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT ""On <br /> INFO �SH RECEIVED BY DATE PERMIT•NO. <br /> EH 13-24(REV.i i e si <br /> EH 14.22 o �� r `�3� 2"9a �o �kI <br /> t <br />