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APPLICATION FOR PERMIT i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 ! <br /> 2FAMIT EXPIRES 1 YEAR FROM DATE_ ISSUED 1 <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instar the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 5.2 5C, C rsj i -Pt- y, City kM Lot Size/Acreage <br /> Owner's Name.! 0 �t?h aOda tet — Address �_��a �[5 n �+ Phone <br /> Contractor &-o—A SM 00j.r. S. Address r I)rr License No. (57G$!�( Phone <br /> TYPE OF.WELL/PUMP: - NEW WELL p WELL REPLACEMENT ❑ DESTRUCTION^Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ �$YSTEM REPAIR ❑ �} OTHER ❑ Monitorifig Well-0- <br /> DISTANCE <br /> ell- 0DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> [ FOUNDATION ..AGR ICULTUREhWEL'L 1t _OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / <br /> f_7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> g <br /> 7 <br /> H,Domestic/Private ❑ Gravel Pack C]-Tracy ;Typg of Casing Specifications <br /> I1 k1blic 1-1 Other r1 Delta Depth,of G out Seal•= Type of Grout <br /> � s <br /> i I Inigati;n —Approx. Depth 1 I EasternSurface Seal Installed by <br /> Repair Work„Done f3 Type of Pump -,H..P_ �` �s1 „�w,e State Work Done <br /> Well Destruction ❑ Well Diameter Sealing.Material & Depth <br /> Depth <br /> Filler Material beDepth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION tX REPAIR/ADDITION I I DESTRUCTION X (No septic system permitted if public sewer is (h <br /> available within 200 feel”I q"�L <br /> Installation will serve: Residence A Commercial— Other !" <br /> Number of living units: _ Number of bedrooms -3 . _ - ' <br /> Character of soil to a depth of`8 feet: WaterAable depth <br /> SEPTIC TANK. © Type/Mfg v Capacity_J_!O O _ Nof"ompartments I <br /> PKG, TREATMENT PLT.0 <br /> /Method o' j <br /> _f Disposal <br /> Distance to nearest: Well I OO Foundation t' 1Property Line�— <br /> LEACHING LINE 0 No. & Length of lines _�__ _ otal length/size 12a <br /> FILTER BED ❑ Distance to nearest: Well D A Foundations. or b Property Line Cl <br /> SEEPAGE PITS 1 1 Depth Si:'e f Number <br /> SUMPS U Distance to nearest: Well �y1C?Q FoundationQ e Property Line_ 0 <br /> DISPOSAL PONDS <br /> CI X 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 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." <br /> The applicant must all for all i d ins ction Complete drawing on reverse side. <br /> Signed X Title; r 40 t" Date: <br /> F PAE&RTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit r Grout Inspection by �- flate` L�� Final Inspection by Date�7 <br /> Additional Comments: JF �l 7l L � 41"' . <br /> _._ <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 95201 <br /> FEECK <br /> INFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEC/J� gPERMIT'N0, <br /> Em 3-24 EHt1.atREV.�ik51 <br />