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Ih <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p _ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> I° P 0 BOX 2009, STOCKTON, CA 95201 f <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISt$UPD <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work hereinldescribed. This <br /> application is made in c;, liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Be ices. <br /> Job Address c ry1. k_u City. Lot Size/Acreage <br /> 99r6_W6[ <br /> 69- <br /> Owner's Name I�'�" ddress Phona? <br /> I-S 7- 596!n-' ,� <br /> Contractor 'i Address License No. Phone <br /> M TYPE OF WELL/PUMP: . illi NEW WELL _ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIO5 ❑ SYSTE �EPA1R ❑ OT SER [ M nitoring Well <br /> .l i <br /> DISTANCE TO NEAREST: SEPTIC TANK 150SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ,.� AGRICULTURE <br /> WE <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. <br /> n Industrial C] Open Bottom ❑ Manteca Dia. of Well Excav 'o Dia. of Well'Casing <br /> -Domestic/Private Gravel Pack ❑ Tracy Type of Casing c 5pecificatioris <br /> fl Public [-1;Other ( Delta Depth of Grout Seal N Type of Gro u't' <br /> I I lfrigation ..Approx. Depth l I Eastern Surface Seal Installed by i <br /> Repair Work Done 0 Type of Pump H.P. State Work Dona <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> D11� Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAMIADDITION I I DESTRUCTION I I (No septic system permitted hif public sewer is <br /> available within 200 feet.l I <br /> 1 LA <br /> Installation will serve: Residence— Commercial___,_ Other <br /> Number of living units: 11 Number of bedrooms <br /> ' Character of soil to a dept Fii of 3 feet: Water table depth <br /> SEPTIC TANK 0 'I Type/Mfg Capacity No. Compartments iM <br /> PKG. TREATMENT PLT. ❑ Method of Disposal iM <br /> Distance to nearest: Well Foundation Property Line I� <br /> Ir <br /> LEACHING LINE 0 I No. & Length of lines Total length/size IM <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> r' <br /> SEEPAGE PITS I I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> .i <br /> DISPOSAL PONDS ❑ Q <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 CountyIL <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the pertormance 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 C rnia." Ij I� <br /> The applica st tali i all r aired in tions. Complete drawing on reverse side, I <br /> Signed X TRIJ?,�_ el <br /> i <br /> f FORD ART SE ONLY i <br /> Application Accepted byDate Are i� <br /> .Ii <br /> r <br /> Pit or Grout Inspection by Date Final Inspection by Date �� G <br /> Additional Comments: <br /> Applicant - Return all copies to: San <br /> � FF op Joaquin County Public Health I� <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 DATE PERMIT No. <br /> INFO �'1, �CC CASH} <br /> . EH 13.24[REV.V Sl -i i � o� aq4 <br /> EH i1.2a � 1 II l <br /> �N �M <br />