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APPLICATION FOR PERMIT <br /> i. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ` 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON' CA 95201 <br /> PERMIT EXPXRES 1 YEAR FROM DATE ISSUED- <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 comp*liance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Hea'lt Bervices. <br /> I ipjJab'Address City Lot Size/Acreage <br /> Owner's Name Address Phone <br /> i r , <br /> y t l F p n7 <br /> 7 Contract Address! *.��rc..�ot7 ( � ?License No. ZfZZ40 Phone <br /> TYPE OF WELL/PUMP: # NEW WELL. 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L <br /> t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ BOTHER ❑ —_ ring Well _C7 <br /> ---' —DISTANCE TO NEAREST:`SEPTIC TANK- 14 ' SEINER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> .I <br /> [7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications < <br /> I'] Public (:I Other n Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation l..Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth , <br /> Deplth Filler Material ✓L Depth S <br /> TYPE OF SEPTIC WORK: NEW iNSTAL�ATION REPAIR/ADDITION { I DESTRUCTION I 1 iNo septic system permitted it public sewer is 6 <br /> 11 `-/ available within 200 feet.) <br /> MInstallation will serve: Residence_ Commercial_' ther <br /> Number of living units: Number of b s �/t <br /> Character of soil to a.depth of 3 feet: Water table depth CJ <br /> SEPTIC TANK Type/MfgZl�d_lCapacity _ T No. Compartments <br /> PKG..TREATMENT PLT. ❑ �y/ Method of Disp�sai <br /> j Distance to nearest: Well 406, Foundation�� Property Line <br /> LEACHING LINE 5X .No. & Length of lines j Total length/size K <br /> `; <br /> FILTER BED`. �,• ❑ bistance to,nearest: Wall Faundatian_ �Q Property Line <br /> If <br /> SEEPAGE PITSDepth Size 36 Number f <br /> w SUMPS Irl Distance to nearest: Well Foundation Property Line <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 /> 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 /> comilies 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 m t call for all- uir inspections. C6rnplete drawing on'reverse si e. <br /> r Signed Title: r Date: ff_ 04a <br /> FOR,DEPARTMENT USE ONLY �J { <br /> Application Accepted by J Dale � t/ Area <br /> Pit or rou nspection by II ate Z inal Inspection by -�r1/// -Tf Date <br /> Additional Comments: I! rF <br /> Applicant-^ Return all clo�pies to: San Joaquin County,Public Health <br /> sx Services, Environmental'Health Permit/Services <br /> t ' 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY `DATE PERMIT'NO. <br /> a EH l3 24 iREV.t/n 5) ,. J° LA/1 3`ej 9 L 9 <br /> EH t4-2e r i <br />