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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PA YpfleVr <br /> ENVIRONMENTAL HEALTH DIVISION Re elv, <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 � �� <br /> P O BOX 2009, STOCKTON, CA 95201 JUN 2 4 toll <br /> SANi <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f cj�2 l.afC t()1AQU1I11 CG'.+n1ru <br /> (Complete in Triplicate) <br /> '..'..y <br /> Application Is hereby"made.to San Joaquin County for a permit to construct and/or install the work herein descx�.;ilMed". .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 /> W --- - <br /> Job Address .` City yr Lot Size/Acreage <br /> Owner's Name avknsAddress Phone gls- <br /> Conttactor '>b4014% � Address`n�� m�( a _. License No. Phon <br /> TYPE OF WELL/PUMP: 'NEW WELL ❑—/ WELL REPLACEMENT C—�/ DESTRUCTION ❑ Out of Service Well ❑ <br /> YPUMP INSTALLATION ltd SYSTEM REPAIR CiY OTHER ❑. Monitoring Well n <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 4 CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> VItblic I-1 Other n Delta Depth of Grout Seal Typeof Groutigation _Approx. Depth I I Eastern Su ce Seal Installed by <br /> Repair Work Done Type of Pump L t H.P. 1 __ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth Tom' <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I k INa septic system permitted if public sewer is <br /> available within 200 feet.] <br /> Installation will serve: "Residence T Commercial— 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. 1 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well 7Foundation " Property Lirie <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 /> i 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 full w g: "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 if ni " <br /> t <br /> The_appii n St c It for II requi -Complete drawing on ev a side. <br /> Signed Title: Datel�/J' � � <br /> R D ARTMENT USE ONLY <br /> Application Accepted by Date 4Area a / <br /> Pit or Grout Inspection by Date Final Inspection by a ata <br /> Additional Comments: fi <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Eavirontnental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> i <br /> IFEE AMOUNT DUE AMOUNT REMITTED 1C K RECEIVED BY DATE PERMIT N0. <br /> + EH1224 TREY,t/A51 ` .: ,"�-' r/ �• '/�t Yj �1� f <br /> EH 14.20 <br />