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APPLICATION FOR PERMIT 'r f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES } <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 3-601 E. HAZELTON AVE. , PHONE (209)46$-3420 { <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RES X YEAR ,FROM DATE ID <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 conspliance with San Joaquin County Ordinance No, .549 and 1862 and the Rules and Regulations of San <br /> Joaquin Colony Publ�ic/ Health Services. a <br /> Lot Size/Acreage 1 99 W%_ ' <br /> Job Address <br /> i to <br /> Phone <br /> Owner's Name <br /> !� %w klS- Phone <br /> Contractor Address License fVo. � <br /> TYPE OF WELL/PUMP: _ s: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION Ll Out of Service Well ❑ <br /> OTHER ❑ Monitoring Well L]PUMP INSTALLATION C1SYSTEM REPAIR ❑ <br /> Y �x SEWER LINES �DISPOSA�L FLD. - _PROP. LINE - <br /> r DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL r <br /> I <br /> s <br /> INTENDED USE TYPE OF WELL PROBLEM AREA'S;,CONSTflUCTION SPECIFICATIONS Dia. of Well Casing <br /> r n Industrial ❑ Open Bottom D Manteca D.ia. of Wall-Excavation Specifications.. 1 <br /> (a Domestic!Private ❑ Gravel Pack ❑ Tracy Type-of Casing <br /> 1"I Public Cl Other ....�.,.;.�C- <br /> Delta Depth:/oj Grout Seal.-f Type of Grout <br /> I ) Irrigation —.Approx. Depth I I Eastern Surface Be i Installed by <br /> H P. _'` tlateyWork Done <br /> Repan Work Done U Type of Pum p & Depth <br /> � �-- <br /> Sealing Materiel ep <br /> Well Destruction D `Weti Diameter <br /> Filler Materiel & Depth <br /> Depth <br /> NEW INSTALLATION I 1 'REPAIR DESTRUCTION- I_lNo <br /> sept <br /> i system tmitd if-�public sewer is <br /> TYPE OF SEPTICWORK; X <br /> Installation <br /> will serve: Residence CommercialOther / <br /> Number off iving units: ,Numtier_.of bedrooms -- �* <br /> + " Water table depth <br /> E Character of soil to a depth of 3 feet: - *� ' <br /> �. Capacity 4, No. Compartments ti> - <br /> SEPTIC TANK' ❑--TypelMfg. <br /> i PKG. TREATMENT PLT. '~! t Method of,Disposal <br /> " -- —•j <br /> Distance to nearest: ¢Well Foundation - -_- PropertJy Line- <br /> , <br /> LEACHING LINE Ll Na. a Length of lines Total length/sire <br /> FILTER BED ❑ Distance-to 66arest: <br /> Well Fou'n <br /> - datian Property Li <br /> �_ ' <br /> r1e <br /> SEEPAGE PITS 11 Depth Sired Number <br /> SUMPSLI Distance to nearest: Well Foundation_ — Property Line— — <br /> i . DISPOSAL PONDS ❑ i" <br /> I'hereby'cenify that I have prepared this application and that the"-work will be done in,accardance with.San Joaquin county ordinances, state laws, olid <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 rn 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 /> issued,tsh8ll,employ parsons subject to comper+s <br /> certifies the following; "l Certify that in rhe parfarmence of the work tor_which.this permit is <br /> r tion laws tit Calitornie.'* <br /> The applicant must ca for required " ons. Complete drawing on reverse side. !f <br /> Date: <br /> _ Signed <br /> FOR DEPARTMENT USE ONLY <br /> L Y\ Date r Area 2 <br /> iApplication Accepted by <br /> Pit Grout Inspection b <br /> Date lU Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Sen 1�u1Aces, EnvionmentaliHealthtServPermit/Services <br /> I 1601 E. Hasselton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT IVO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> w 1 <br /> . EH 13124 MEV.1)R5) K �t�,�v y �fQO <br /> EH 1-26 1 <br />