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f <br /> 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 /> PERMIT EXPIRES 1 YEAR FRPM,.DATE ISSUED <br /> (Complete in Triplicate) <br /> E <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 T� � 1� - - Cir Lot Size/Acreage <br /> i <br /> Owner's Name ` i. Address tJE/ za Phone <br /> w Contractor _ Addresses License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r a DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing <br /> i1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing s Specifications <br /> U1 Public 17 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I !-Irrigation _.Approx. Depth I i Eastern Surface Seal Installed by V <br /> Repair Work Done Type of Pump z,-del H.P. tate Work Done 4 <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth - Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION tA (No septic system permitted if public sewer is '3 <br /> k available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms xl <br /> Character of soil to a depth of 3 feet: _ 4 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity "No. Compartments <br /> PKG. TREATMENT PLT. ❑ - Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> k LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS IJ Depth Size Number ' <br /> I SUMPS 0 Distance to nearest: Well Foundation Property Line t <br /> DISPOSAL PONDS ❑ ' <br /> I hereby certify that I have prepared this application and that the work-will be done in actor,"dance 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 ceitifies:the following: "I certify that*lh the performance of the work for which this permit is issued, I shall not r <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." <br /> The applicant Murat call for all required inspections. Complete drawing on r erre side. <br /> Signed X d. m(L(-e, Title: x Date: <br /> r <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Datej Final Inspection <br /> Additional Comments: <br /> Applicant - Return all copies to: Sam Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE CK 4 <br /> INFO AMOUNT <br /> ,,,,DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> l EH 13-2/1REV.I/H si /'�!/�-y OD [!� a-L <br /> .26 <br /> EH 14 <br /> E <br />