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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, STOC%TON, CA 95201. <br /> RERNIT EMPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete iia 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 Frith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Publics Health S/eervvices.,. <br /> Job Address _-_ � ! IBA A OT) Ad, f Cit t Size/Acreage <br /> Owner's Name t`{ !„ 1,.,.., (C Address _ ivr� �.. Phone <br /> Contractor Address ` License N Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PS.-..— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP .` <br /> C] Industrial ❑ Open Bottom ❑ Manteca �Depth <br /> xcavation Dia. of Well Casing <br /> ['I Domestic/Private ❑ Gravel Pack ❑ Tracy f Casing Specifications <br /> I'l Public Cl Other a of Grout Seal Type of Grout <br /> I irrigation _ Apitmox. Dep 1 1 Eastern Surface Seal Installed by <br /> Repair Work Done v 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 WOR"EW INSTALLATION I I REPAIR/ADDITION <br /> DESTRUCTION i I ifVo septic system permitted if public sewer is <br /> I <br /> available within 200 feet.) <br /> Installation will serve: Residence_� Commercial_ Other r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I F-,. Water table depth <br /> SEPTIC TANK ❑ Type/Mfd l t Capacity fi No. Compartments <br /> " / `7 ► r r <br /> PKG. TREATMENT PLT. ❑ a Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No, 9 Length of lines Cf i .. r _ TotaL`lengthlsizet <br /> FILTER BED ❑ Distance to nearest. Well f- -Foundation.) c� Property`� ' <br /> Cine <br /> P. <br /> SEEPAGE PITS Depth __ _ _Size* W Number <br /> SUMPS LI Distance to nearest: Well,,!; - -1-Foundatiorr1 - •_ Property Line _ y <br /> DISPOSAL PONDS © I t �. 'i 4 . i <br /> I hereby certify that I have prepared this application and that the work will be don;'in acCcRdanee with San`Joaquin county ordinances, state laws, an <br /> 9 <br /> rules and regulations of the San Joaquin f County t <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wok 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 i6oed, I shall employ persons subject to workman's compensa- <br /> tion laws of California." i. ..» ._ <br /> The applicant t call for all requir ins ctions. Complete drawing on cowirse si f f <br /> Signed X Title: �y'_,/I ' / <br /> Date: __. <br /> MENT USE ONLY <br /> Application Accepted by fI77 Date Area �1 <br /> Pit or Grout Inspection by + Date Final Inspection by Date 1 <br /> Additional Comments., I <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 /> INFE AMOUNT DUE AMOUNT REMITTED CK 9 <br /> CASH RECEIVED BY 1 DATE PERMITNO. <br /> r EH 13.24(REV.1/N5) <br /> EH 1.626 <br />