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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 /> EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) J� <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 ty Lot Size/Acreage ,�f'NP �-- <br /> � <br /> 1 i <br /> PY_92 ti Cyt!l ECC Address Phone <br /> Owner's Name - – — ' <br /> License No. 7 Phone ���� <br /> Contractor Addiesw 7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> Monitoring Well <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 /> n Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Wel! Casing <br /> F] Domestic/Private 0 Gravel Pack L1 Tracy Type of Casing Specifications <br /> I't Public CI Other n Delta Depth of Grout Seal - Type of Grout <br /> I I Irrigation ____ Approx. Depth I i Eastern Surface Soul installed by <br /> Repair Work Done IJ Type of Pump H.P. State Work Done j <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth ­FfTle`r'Mateiiai & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION^INo septic system permitted if public sewer is <br /> aNavailable 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 depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> II Distance to nearest: _Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines , Total length/size <br /> li FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> it 0 <br /> SEEPAGE PITS 11 Depth Size Number 7 <br /> y Y <br /> SUMPS LI Distance to nearest: Well Foundation Property tine <br /> DISPOSAL PONDS ❑ y' <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 I <br /> Home owner or licensed agent's signature certifies the following: "I canify 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 applic t ust call It re i d spe 'ons. Complete drawing on reverse side. <br /> Signed X Title: cZige–ce Date: 2 <br /> OR TMENT USE ONLY <br /> Application Accepted by Date Area <br /> j Pit or Grout Inspection by Date Final Inspection b� ' Data <br /> 4 <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 ox 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATH_ n <br /> INFO <br /> + EH 19.24(REV,r/1451 .� S �,�C?� V S 5�-a <br /> EH 14.26 <br />