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a* <br />�. ADPLICAT1 N�FOR PERMIT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)51168-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EBMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application`is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cotspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> }� 0 <br /> Job Address �* azo0 City - f 4= Lot Size/Acreage <br /> C <br /> Owner's Name Address Phone <br /> Contractor A G/Z L Address72 QW�_icense No.: Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR)IC OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Weft Excavation Dia. of Well Casing <br /> l <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"1 kl 7ther4t , r �pet�aPublic 171 <br /> Depth of Grout*Seal Type of Grout <br /> I I Irrigation _Approx, Depth -,.I'1 Eastern __ Surface Seal installed.by <br /> Repair Work Done r �Type of Pump ' s 'H,P, :'_ "'2 ""�-' " ' State Work Done 1 <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth 1 <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is <br /> -'> available within 200 feet ) t� <br /> Installation will serve: Residence— Commercial ° Other <br /> f p • + t <br /> Number of living units: Number of bedroo.ms+ <br /> Character of soil tq a depth of 3 feet: I Water table depth <br /> SEPTIC TANK t, ❑ Type/Mfg Capacity No. Compartments ' <br /> PKG. TREATMENT PLT. C7 t Method of Disposal <br /> Distance to nearest: t Well Foundation Property Line <br /> ` i k_e <br /> LEACHING LINE; �' 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ; Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: -Welt -Foundation' Property Line r <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 4 , `. `4 't <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 shelf not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting 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." I .. - --- <br /> ""s <br /> ..... - <br /> The a ausicor all re aired i ctions.- omplete drawing on r o rssee side. <br /> Signed " / a <br /> Title: Date: Q <br /> t .. <br /> sry f; F. DEPARTMENT USE ONLY <br /> Application Accepted by �` e Data 2 — Area I <br /> Pit or Grout Inspection by Date ' 3 / <br /> Final Inspection by Date <br /> Additional Comments. 1 <br /> t <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 I <br /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'N0. 5 <br /> INF CASH <br /> a EK 13-24 tREV.4/X 51 <br /> EK 14-1211 <br />