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APPLICATION FOR PERMIT 41 717 ' <br /> SAN JOAQUIN COUNTY, PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL�HEALTH DIVISION <br /> 1601 E. HAZELTON AVE�,'PHONE (,209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM-DATE 15SUED <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 Ser/vi�c s. <br /> Job Address 3 �O `�ah�� • ' -- City Lot Size/Acreage <br /> I {ll�, 1) �] � r J6sif dOD� Phone <br /> Owner's Name Address <br /> .p� c�'3 S �i C <br /> Contractor�'`��� _! y �r-_Address & w S1License No 1��" " Phone ZZIG <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well D <br /> 9 PUMP INSTALLATION SYSTEM REPAIR &_11, OTHER © Monitoring Well ❑ <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 /> Cl Industrial O Open Bottom ❑ Manteca Dia. of:Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications <br /> I <br /> I"I Public El Other Cl Delta Depth of Grout Seal Type of Grout I <br /> I I Irrigation Approx. Depth K Eastern Surface Seal Installed by <br /> Repair Work Done * Type of Pump S H,P. _ State Work Done <br /> Well Destruction D Well Diameter pr. - Sealing Material A Depth ` <br /> i Depth Filler Material &,Depth <br /> rj" , <br /> J TY,PE,OF SEPTICSWORK: NEWINSTALLATION 1y REPAIR/ADDITION t I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> Ty �y\ I ',mss , available within 200 feet.I <br /> Installation will serve: Residence— Commercial! Other <br /> t yNumberyyof .diving units: Number of bedrooms <br /> Chtsracte�`of Soil to a depth of 3 feet: -- Water table depth <br /> SEPTIC TANK 1 0 Type/Mfg Capacity T No. Compartments ' <br /> G, TREATMENF.PLT, ❑ ' <br /> -� *� - } �` <br /> f K _ Method of Disposal <br /> --t��.Distance-to_nearest:. -w-W_eli--- -----Foundation•------ --— Property-Line— <br /> LEACHING <br /> roperty-L-ine-LEACHING LINE ❑ fVo+ 9 Length o41ines Tdtfil length/size <br /> FILTER BED t ❑ Distance to nearest: Well t r Foundation Property Lina i <br /> y� ;-s tir �,, �r f <br /> SEEPAGE PITS <br /> S I I Depth LM�Srze, - -.�, f�Eumber <br /> SUMPLI Distance to nearest: Well Foundation i Property Line <br /> DISPOSAL PONDS ❑ t--.:�—I- J , ' 'a uA / f <br /> hereby certify than I have prepared this-wappIRWIi0trand_that the work will be'do a in'iccordance with SaqJoaquin county ordinances, state laws, and <br /> rules and regulations of the Sante oaquin County '��.� <br /> Home owner or license ! nature certifies the following: "I certify that in the performance of th'e work for which this permit is issued, I shall not <br /> employ any person i uch manner to become subject to workman's compensation laws of California.' Contractor's hiring or sub-contracting signature <br /> certifies the folio ' `g: "I ertify that n the performan f t e w or hich this permit is issued, I shallermploy persona subject to workman's compensa- <br /> tion laws of Ca ornla." / <br /> The applicant mus f re ed ins c ' at ng re <br /> Date <br /> Signed ; f <br /> tt : <br /> FO DEPARTMENT USE ON Y <br /> r1 �S <br /> Appilcatlon Accepted by _ t.�i. l a_ C+_..�.�`.�:' Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional CommJnts: ✓ �� <br /> Applicant - Return all copies to`: San-Joaquin County-Public Health <br /> s ! Services, Environmental Health Permit/Services <br /> 3k <br /> --'1601Z-`Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO i AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. <br /> EH 1`221 IREV,I/R5) 1 l 5,o-o ��r�.� 42± <br /> O"� /l/ ID—I <br />