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APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> g (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 1$62 and the Rules and Regulations of San <br /> Joaquin County Pu`b'lic!_ ti <br /> Heaallth?Services. J / <br /> Job Address __ _l to c��] �G' �r y/ _S - 9 Cityi^'laI1 - <br /> _QeLot Size/Acreage <br /> Owner's Name o eCi e0, Address Phone p <br /> a <br /> n <br /> Contractor 1.. f Address License No. S1Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C) Out of Service Well ❑ <br /> a: PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring Well G7 <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 <br /> F Industrial ❑ Open Bottom ❑ Mance"ca'_­`"" Dia:-of Well Excavation Dia- of Well Casing f <br /> fa <br /> Domestic/Private ❑ Gravel Pack ❑'Tracy Type of Casing Specifications <br /> I'I Public (D Other I1 Delta_ Depth of Grout Seat Type of Grout <br /> Il Irrigation -Approx. Depth f 11 Eastern Surface Seal Installed'by <br /> Repair Work Done ❑ Type of Pump . H,P. State Work Done <br /> 4 Well Destruction ❑ Well Diameter ti; Seahng•Material-B.Depth f ' <br /> Depth Filler Material & Depth -' <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATIONREP-AIR/-A@DIT+ON•i•I-�7DESTRUCTION [ I INo septic system permitted ifspublic sewer is <br /> S �;available within 200 feet.) t <br /> Installation will serve: k e�`i e" Commetzialt .Other <br /> 14 Number of living units: A_ 'Number of bedrooms <br /> Character of soil to a depth of 3 feet: , Water table depth s <br /> SEPTIC TANK 1 Type/Mfg _ gip• -L r Capacity___ � No. Compartments <br /> PKG. TREATMENT PET.'❑ r f Method of Disposal { <br /> Distance to nearest: WellQb Foundafion' _ Property Line Ann_ I n <br /> ~ V i <br /> LEACHING LINE V10,No.yf9 Length of lines Nota! length/size. <br /> FILTER BED ❑ Distance to nearest: Well. 100-t Foundation - Property Line_Ina-t i <br /> SEEPAGE PITS 1 I Depth { _sizek Number 3 <br /> SUMPS 1tf Distance to nearest: Weil Foundafio`n�� Property Line <br /> DISPOSAL PONDS El <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County; -4 <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 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 of California." 4Z, <br /> k The applicant must c;il r all requirep inspections. Complete drawing on reverse side. / <br /> Signed { I Title. c�'0 Date: <br /> ! i � <br /> FOR DEPARTMENT USE ONLY } c <br /> f Application Accepted by ✓h�-- _, __.Y Date_I �� <y Area Z <br /> II w <br /> Pit or Grout Inspection by Date Final Inspection by� Date 1 � <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 2009, Stockton, CA.. 95201FEE CK 9 <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13-24 rREV.wiw5l <br /> EH ) LI '�� <br /> Z�.� L <br />