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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 O BOX 2009, STOCKTON, CA 95201 <br /> PRRMI EXPIRES 1 YEAR FROM DATE ISEU <br /> (Complete in Triplicate) <br /> hereby made to San Joaquin Count for permit to construct and/or install the work herein ded ,Lea This <br /> Application is he y q Y <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regu]at"3$ns f San <br /> Joaquin County Public Health Services. /� <br /> r Lot Size/Acreage <br /> Job Address City <br /> Owner's Namecz�� <br /> Address "_ Z&, _ Phone <br /> 4 <br /> �f ] �7Z6 <br /> Contract Address r`` ' ` 4 License No, _T Phone -3!4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f <br /> Ca Domestic/Private Gl Gravel Pack C Tracy Type of Casing Specifications <br /> I'I Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I i Eastern Surface Seal.Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ DOITIONTZ DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 206 feet.) <br /> Installation will serve. Residence Commercial_ Other , <br /> Number of living units: -/— Number ofooms_. f <br /> Character of soil to a depth of 3 feet: �9- �,. --- _Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityZ_2062 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No, & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property..Line <br /> SEEPAGE PITS Depth Size is Iiumbet <br /> SUMPS El 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 /> 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 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mst c for all eq !i4red Complete drawing on reverse i e <br /> r C <br /> Signed Title: . - Date- <br /> FORTMENT USE ONLY <br /> Application Accepted by r / Date ' Area <br /> 61 4 Grout Inspection byate `�` r Final Inspection by Date <br /> t <br /> Additional Comments: <br /> Applicant - Return all copies to. San Joaquin County Public Health <br /> Services, Pavironmental`Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO ((jj CASH <br /> ♦ EH 13-24 MEV.r/A5� f T��� <br /> EH Z4.2a 1 ll 111 <br />