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f I` <br /> APPLICATION FOR PERMIT <br /> ! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION R INO:C E I'VE <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> , ,� �gf <br /> P O BOX 2009, STOC&TON, CA -95201 II <br /> 1. <br /> ENVIRONMENTAL HEALTH <br /> kFMIJ EXPIRESI YEAR FRQM DATE ISSUED RERMiT/SERVICES <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct end/or'install the work herein described. This <br /> application is made in compliance with San Joaqui County Ordinance No. 549 and 1862 and the Rules and Regulations of Sen <br /> Joaquin County blic Health Services. <br /> ,I. <br /> -7LJP) <br /> Job Address It Lot Size/Acreage <br /> .k <br /> Owner's Nam Phon9 <br /> r <br /> mise, No. honeg2/ - <br /> i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION O Out of Service Well ❑ <br /> ` PUMP INSTALLATI� SYSTEM REPAIR O OTHER O Monitoring Well C7 <br /> DISTANCE TO NEAREST: SKEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> l fOUNDATION AGRICULTURE WELL OTHEfi WELL PITS/SUMPS <br /> If INTENDED USE ,'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ) <br /> L-1 Inc trial OlOpen Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mestic/Private O Gravel Pack 0 Tracy Type of Casing Specifications <br /> l I'1 Public Cl Other Cl Delta Depth Type of Grout <br /> I I Irrigation .-.Approxi Dept 141 ster r Surface Seal Installed by I, u <br /> Repair Work Done U 7ypa of Pum H.P. State Work Don r <br /> Well Destruction ❑ Well Diamettirf Sealing Material & Depth <br /> I <br /> Depth 1 , Filler Material,& Depth �f C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I 'DESTRUCTION I I INo septic system permitted if public sewer is <br /> Biu - d available within 200 feet.) <br /> Installation will serve: Relidence? -Commercial— Other <br /> Number of living units: 1M Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth li <br /> SEPTIC TANK ❑ Type/Mfg j Capacity`s No. Compartments <br /> PKG. TREATMENT PLT. D f ` r ) Method of;Disposal <br /> 1 Distance to nearest: Well Foundation Property Line <br /> r LEACHING LINE O No.,.& Length of lines [ Total length/size <br /> FILTER BED [-I Distance to-nearest: Well Foundation Property Line <br /> I 'V ! I <br /> SEEPAGE PITSs 11 i Depth _ Sire Numbers <br /> x <br /> SUMPS M LI Distance to nearest: Well Foundation Property Line <br /> l DISPOSAL PONDS ©_ <br /> I hereby certify that I have prspared 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 <br /> Home owner or licensed agent's signature certifies the fotlowinT "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 persons subject to workman's compensa- <br /> tion laws o C ' nia." <br /> The a lic t rhu ca for all red in Clio s. Complete drawing on rove side. <br /> Iq <br /> igne Title: Date: <br /> P <br /> FO DEPARTMENT USE ONLY Z /` <br /> I / �� <br /> ` Application Accepted by Date Are <br /> Pit or Grout Inspection by Date Final Inspection by Dat J� <br /> Fr Additional Comments: <br /> Applicant - Return all clopies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK 9 <br /> FEE• INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24• EN t4.Ze IREV. 7 <br /> r i n 514� <br /> _ IN J <br />