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f APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> I ENVIRONMENTAL HEALTH DIVISIONR E ' ' c <br />° 1f0I E. HAZELTON AVE. , PHONE (209)4&, 8-$4 E IV <br /> P O BOA 2009, STOCKTONCA 95201 <br /> r MAY 3 <br /> aPERMIT EXPIRES 1 YEAR FROM DA E ISS VIRQNMENTAL HEALTH <br /> (Complete in Triplicate) _ <br /> Application is hereby'made,to San Joaquin County for a permit to'construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Address <br /> D Phone <br /> C t r �[��- s �i <br /> Llcerrse No. Phone <br /> TYPE OF WELL/PUMP: NEW WEL�L ❑-/ WELL REPLACEMEN ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK // SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL` —PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �;.iestic/ <br /> ustrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ' <br /> i Private ❑ Gravel Pack ❑ Tracy Type of Casing- <br /> Specifications <br /> V) Public C) Other ,FI Delta Depth of Grout Seal Type of;Grout <br /> I f Irrigation _.Approx. Depth l E stern f/$uI�rfaee Seal Installed by <br /> Repair Work Done C] Type of Pump H.P. /oG _ State Work Don <br /> Well Destruction 0 Well Diameter �� Sealing Material & Depth <br /> Depth_ ' / Filler Material & Depth K1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION E I DESTRUCTION i I {No septic system permitted if public sewer is <br /> available within 200 feet.► <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table dap <br /> SEPTIC TANK. ❑ Typaffvlig Capacity No. Compartments' <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size <br /> g � <br /> Number � <br /> SUMPS LI Distance to nearest: Well <br /> DISPOSAL PONDS CI Foundation property Line o <br /> r �+ <br /> 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: "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 compensatiori 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 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican u t,cap u'ed inspe.ctOns. Complete drawing on rev se side. <br /> Sig ed <br /> Titl Date: 2� <br /> ' 4 � <br /> F EPARTiV1ENT USE ONLY' / <br /> Application Accepted by Date �- Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 CK t <br /> INFO CASH RECEIVED BY DATE PERMI7'NO. <br /> • EH 13-24(REV.r/R5)& <br /> EH 14.26 <br />