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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 O BOX 2009, STOCKTON, CA 95201 —o6 o v <br /> RERMIT EXPIRES 1 YEAR FROM DATE IS.9UED <br /> (Complete in Triplicate) �S�� C# � <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 Ckerb eg- tf' n eL,4-�7-1 fl) City Lot Size/Acreage GvG S <br /> 4 <br /> Owner's Name . 5?_ •�, e `s Addresses Phone _ `� �-� <br /> � s F�Mr•� 4 9KG- �f� 7L Sphon�c31^ <br /> Contracto Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT 0 DESTRUCTION,.GI out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ { OTHER ❑ I Monitoring Well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLS:"- -�" PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL = SPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [a Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'] Public 0 Other {I Delta Depth of Grout Seal Type of Grout <br /> I1 Irrigation �.Approx. Depth [ I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I <br /> DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial-4 Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table'''depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ '}157-e,E 1 3 &Snn P cc V-Meer L� CYK" Method pf_DisVsal uy <br /> Distance to nearest: Well Foundation Property Line i °. <br /> LEACHING LINE Cl No. & Length of lines Total length/size r r y r <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> n. <br /> i <br /> SEEPAGE PITS 11 Depth Size Number- <br /> SUMPS <br /> umberSUMPS LI Distance to nearest: Well Foundation Property.Line <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 ` . t ! i I <br /> Home owner or licensed agent's signature canities 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 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-, ` <br /> tion laws of California." <br /> The applicant must call for all req d spectio s. CompI t drawing on reverse side. <br /> Signed Title: Date: <br /> F R DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by S Date <br /> Additional Comments: <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 2DO9, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'N0. <br /> I <br /> + EH 13-21 1RtV. 51 <br />