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APPLICATION FOR PERMIT <br />{ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> j ENVIRONMENTAL HEALTH DIVISION <br /> i 1'601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to SaoJoaquin 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 AddressCity "� W lot Siz /Acreage <br /> (�0#~W` W �10/f C <br /> Owner's Name Address ice✓. Phone <br /> a` �,,� + �/f�q� Y <br /> .Contractor " Address AJC` f �� [Ljcense No. �T i� � Phone d <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT CJ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELLPROS .-CONSTRUCTION SPECIFICATIONS- ' <br /> ❑ Industrial ❑ Open Bottom df ❑ Manteca Dia. o cavation Dia. of WeIC'Casing <br /> Ca <br /> Domestic/Private ❑ Graver Packr L1 Tracy Type of Casing Specifications <br /> Cl Public C-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> i i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by3 <br /> Repair Work Done 0 Type of Pump H.P. State Work bona T V <br /> Well Destruction , D Well Diameter f Sealing Material & Depth 1 <br /> Depth f - Filler Material & Depth n > <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I i (No septic system permitted if public sewer is <br /> tf f available within 200 feet.) ` <br /> Installation will serve: Residence-&.t Commercial_ Other I <br /> i ! <br /> Number of living units: I Number of bedrooms _ � L t <br /> Character of soil to a depth of 3 feet: Water'table depth . <br /> SEPTIC TANK ❑ Type/Mfg,1 i Capacity,— � No.(Compartments <br /> PKG. TREATMENT PLT. ❑ t <br /> r Method of Disposal <br /> Distance to nearest: Well Foundation '`� Property°Line <br /> LEACHING LINE No. & Length of lines O To- <br /> FILTER <br /> o-FILTER BED Or Distance to nearest: Well Foundation.' - ----.property Line <br /> SEEPAGE PITS Depth p Size <br /> SUMPS I Distance to nearest. Well '' j <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will bedone n accordance with.San,Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Countryly : <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,"cCcntractor's.hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which,this-permit-is,issued;"I,shall employ persona subject to workman's compensa- 1 <br /> tion laws of California," i Te [c 4­ <br /> for <br /> The applicant m t call for all required ' """` +�T" <br /> q pact' ns CompI ote drawing reverse side. r <br /> Signed ` _ "�• Title: <br /> Date: J 90 <br /> f„x0y FOR DEPARTMENT USE ONLY <br /> Application Accepter! by ' Data / r � Area <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <br /> 4 <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 RECEIVED BY PATE PERMIT N0. <br /> INFO CASH <br /> + EH 2 IAEV.iiNSi <br /> 14. <br /> EN 3�•2s S <br />