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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 0 BOX 2009, STOCKTON, CA 95201 <br /> 2EMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 1 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 1662 and the Rules and Regulations of San <br /> Joaquin County pPublic Health Services. <br /> Job Address a f.Fo 6 <br /> City Lot Size/Acreage <br /> t Owner's NameRA� Address R02C A15 0 Phone <br /> P _ <br /> Contract&"a4u,Aaa 00 Address P,0 <br /> License No.kPY2-ZG Phone3k -_,5-dO�5 <br /> TYPE OF WELUPUMP:' NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ <br /> -. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ._ -OTHER-0 Monitoring Well 0 <br /> r' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications <br /> I'1 Public 1:7 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrioation .Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> I Well Destruction ❑ T.Well-Diameter . Sealing Material A Depth <br /> j Depth Filler Material 6 Depth-__ _ t3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR ADDITION DESTRUCTION i I (No septic system permitted if public sewer is b <br /> ' - available within 200 feet.) <br /> Installation will serve: 'Residence_S,Commercial_ Other v <br /> Number of living units: Numbero b droom <br /> Character of soil to a depth of 3 feet" Water table depth (� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El I,- . Method of Disposal <br /> Distance to nearest: Well's Foundation "^ Property Line <br /> LEACHING LINE Cl No. S Length of lines _' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well ' Foundation Property Line <br /> SEEPAGE PITS � Depth Size Number <br /> SUMPS LI Distance to nearest: Well,[0-Q-`-Foundation 40.�— Property Line L57- <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work vvslt 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 following; "I certify that in the Perfarmance-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 ftiNowing:'`f certify that in the performance of the-work for which this permh-is 'I shall issued, einplo <br /> i' tion laws of California." 'w y persons subject to workman's compensa- <br /> The applicant.m call : a .'9' red tnspeetiohs. Completer drawing on reverse s' e <br /> Signed K Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by If <br /> 6JDate / Area <br /> 6or Grout Inspection by Date ` Final Inspection by ! &__r <br /> Dater <br /> Additional Comments; L <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Rovironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT'N0. <br /> INFO CASH I <br /> r <br /> • EH 13.24 IREV.tin 5� <br /> EH 14.20 <br />