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APPLICATION FOR PERMIT <br /> k, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �. 1601 E. HAZELTON AVE. , PHONE (209)468-3420 t <br /> IP O BOX 2009, STOCKTON, CA 95201 <br /> DiZRL'T':` EXPIRES 1 YEAR FR M DATE SSU <br /> PERMIT <br /> (Complete in Triplicate) <br /> Application is hereby made to S"laquin 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 /> t <br /> Job Address City ,r�yG Lot Size/Acreage � <br /> i <br /> // Address Phone <br /> Owner's Name r �( <br /> / r -2 ��� License No e.a O 7y Phone 'T � <br /> Conuacto Address <br /> TYPE OF W L/PUMP. NEW WELL ❑ WELL REPLACEMENT �1 DESTRUCTION ❑ Out of Service well <br /> ❑ <br /> Monitoring Well C_1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ <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 /> C Industrial 0 Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> Specifications <br /> Cl Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing <br /> t I'1 Ptiblic Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I lrri)ation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction Cl Well Diameter <br /> Sealing Material b Depth <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION ills septic system permitted if public sewer is <br /> available within 200 feel.) n <br /> Installation will serve: Residence_1 Commercial_ Other .�✓ <br /> Number of Rving units: Numbir of bedrooms <br /> Character of soil to a depth of 3 feet:;I Water table depth <br /> SEPTIC TANK• O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & length of lines _ Total length/size r <br /> FILTER BED EI Distance te'nearest: Well Foundation Property Line <br /> .1 .D <br /> SEEPAGE PITS 11 Depth _�1 Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> wing: "!certify that <br /> Home owner or licensed agent's signature cenifies the foltoat In the performance of the work for which this permit issued, 1 shall not <br /> employ any person in such manner as to become a biect to workmen'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 Califo�7 <br /> The applicant/ rust tail f i it in pBctions. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> ---- FOR DEPARTMENT USE ONLY / <br /> Application Accepted by �� Date Alae—� r <br /> Pit or or Grout Inspection by Data Final Inspection by Date " �o_ <br /> Additional Comments: <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 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO p <br /> . EH 13.24(REV.I/n 51 0 3� V U S� 90 <br />