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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ID <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 /> [Fi <br /> Job Address ity Lot Size/Acreage <br /> `� <br /> Owner's NamesZ lU-a1T1�Address Phone i <br /> Contractor Address 0 License Phone <br /> TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"I Public D Other n Delta Depth of Grout Seal Type of Grout <br /> I i Imitation —.Approx. Depth I I Eastern y"�"`"-Surface Seal Installed-by--""'•—" <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material,& Depth . <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 lNo'septic system permitted if public sewer is <br /> I available within 200•feet.l <br /> Installation will serve: Residence_f�----'Commerciat_____, Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to ad;;tth of 3 feet: . Z✓�s� .:..t -`" y _-Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg _tea Ca clty� No. Compartments <br /> PKG. TREATMENT PLT. L7 y �l � `Method of'Disposal <br /> Distance to nearest' Well FOUndatit ,OProperty Line <br /> LEACHING LINE No. & Length of lines �?U � \Notal length/size 6--0 <br /> FILTER BED (1) Distance to nearest. Well,,, �Foundation r F� Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> r <br /> SUMPS [_1 Distance to nearest: Well ' {Foundation Property Line �� r <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 must call for all required inspections. Complete.drawing on reverse side. <br /> Signed X Title: Date: <br /> F DEP f1A ONLY �i <br /> Application Accepted by at o Area / <br /> Pit or Grout Ins ction b Data Final Inspection by <br /> Data <br /> pg Y <br /> Additional Comments: - <br /> Applicant - Return all copies to: Sen Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 x , <br /> FEEAMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO r 1, <br /> EH 13.24(REV.I/n 51 <br /> EH 14.2E f 1 <br />