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F <br /> i <br /> 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 <br /> PERMIT EXPIRES -1 YEAR FR M D Y <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_l^e1M2r h <br /> Job Address 5 0 l� -^1�r�Slr1G�r� t� 6 City Lot Size/Acreage <br /> Owner's Name �q- � Address _Ni�5+�� t hC+ Phone 9� �3Z� 3 <br /> Contfactor WE 1R� Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> C1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing I1 <br /> 1-1 Domestic I Private Gravel Pack F Tracy Type of Casing `'0 -,�`J L Specifications .Ru 9 ``S:`�d <br /> l'1 Public Cl Other Cl Delta Depth of Grout Seal S-R4CID '6 Type of Grout Ca'4-4A-444­0 <br /> I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed byS;a`" �L <br /> Repair Work Done L7 Type of Pump NT's H.P. State Work Done <br /> Well Destruction ❑ Well Diameter 'F— Sealing Material & Depth Gxxlr_ -L <br /> Depth Filler Material & Depth 5-"'' " &- <br /> T PE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is G <br /> available within 200 feet.I <br /> Installation ' serve: Residence_ Commercial— Other I <br /> Number of living un - Number of bedrooms <br /> Character of Boil to a depth o at: ater table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: We Foundation Property Line <br /> LEACHING LINE ❑ No. & Lengt Ines Total length/size <br /> FILTER BED ❑ Dist to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DI.S SAL 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, wale-news, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies 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 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 California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> �.. � fie^ G1ao j�� <br /> Signed �,, "Title: s'k� Date: <br /> F DEP ENT USE ONLY '? <br /> Application Accepted by moi, Date <br /> Pit or Grout inspection by Date �w Final Inspection by Date <br /> Additional Comments: <br /> r <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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EM 13•24IREV,t/Hsi 3S r <br /> EH 14.26 S• ,Oo L137 a <br />