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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ; <br /> ENVIRONMENTAL HEALTH DIVISION <br /> X1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> i� P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR_FROM_DATE ISaUED ' <br /> (Complete in Triplicate) <br /> Application in 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 Health Services. <br /> Job Address `� �0��7�? City SCc�fci� Lot Size/Acreage <br /> �M _ <br /> Owner's Name + �' n¢�� Address Phone <br /> Contractor^ tt;f�. t C Address LDJ ax 114 � License No. 7 Phone SS 16)S <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well �� I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> ;W <br /> INTENDED USE TYPE OF ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [a Domestic/Private ❑ Gravel Pack - 0 Tracy—Type of-Casing t, Specifications <br /> TI<I Public fa Other C n Delta Depth of Grout Seal Type of Grout <br /> — <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done D rType of Pump H.P. State Work Done _ <br /> Well Destruction �O Well•Diameter Sealing Material & Depth <br /> Depthw �i Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION E I 'REPAIR/ADDITION DESTRUCTION i I INo septic system permitted it public sewer is <br /> available within 200 feet.M <br /> Iristallation will serve: Residence M Commercial OthWr""'""' <br /> Number of living units: _j_ _ Nurriber'of bedrooms ~- <br /> Character of soil to a depth of 3 feet: Su►( •. t Water table depth <br /> SEPTIC TANK. w❑ Ty ' ' ��fCapacity No. Compartments <br /> PKG. TREATMENT PLT:❑ li - '""`--- ---» aMathod•of-t�isposal <br /> Distance to neatest: Well "Foundation Property Line t <br /> F <br /> LEACHING LINE �,Y No. & Length of lines Total length/size -=!z_n <br /> FILTER BED ❑ Distance)to nearest: ­Well— Foundation --_ Property Line <br /> SEEPAGE PITS ll Depth� Size ` J V ; Number f <br /> SUMPS r❑ Distance`to nearest: Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ I� <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 /> rules and regulations of the San Joaquin County <br /> Home owner 0►licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall n�t (� <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or'sub-contracting signatur�- <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 workma s compensa- <br /> tion laws of California." a <br /> The applicant must call for all requi ad.inspections. Complete drawing on reverse side. <br /> Signed 3 Title: 1 ./, Date: [� <br /> F DEPAR ENT USE ONLY -.:,--- —-- <br /> a <br /> Application Accepted by _ /���,,,,,, ,,.,,,,.. __ Date / Area <br /> Pit or Grout Inspection byI� Date Final Inspection b �— Da[e � <br /> l t <br /> Additional Comments: I� <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Mnvironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE�� AMOUNT REMITTED ff ASR RECEEVED BY DATE PERM17 NO. <br /> r <br /> a EH -21IREV.finSi <br /> A �1 rlsl 2, <br />