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a.1 <br /> ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOIL 2009, STOCKTON, CA 95201 <br /> k EXPIRES 1 YEAR FROM DAIE ISSUM <br /> (Complete in Triplicate) <br /> r <br /> t 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / fj <br /> Job Address C21 ity �T Lot Size/Acreage <br /> Owner's Name Address'• <br /> Phone ` C% <br /> �L�VZSI <br /> e`'' t> S13a;- --Phone � ! V46 <br /> Contractor Address icense No. <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT M DESTRUCTION C1 Out of Service Well <br /> PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r .FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, ` <br /> 11 Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation '+ Dia. of Well Casing <br /> P Domestic/Private q O Gravel Pack ❑ Tracy Type of Casing Specific tons <br /> Il Public C] Other �:1 _A• "f�`Delta Depth of Grout Seal #' Type of Grout <br /> I I Irrigation _.Approx`Deptli, l I Eastern Surface Seal Installed by - <br /> �-_ <br /> Repair Work Done ❑ Type of Pump•---- . H.P, State Work Done <br /> Well Destruction ❑ Well Diameter - _ Sealing Material & Depth <br /> Depth ' <br /> Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION VP DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence 4 Commercial— Other <br /> j Number of living units: ..._- Number of bedrooms rJ�= f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> t SEPTIC TANK"-•-OT :Type/Mfg- - Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE No. & Length of lines Total length/size_ 4r <br /> FILTER BED ❑f Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth i f Size 3Z T Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this appllcation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> {p 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 /> 3 employ any person in such manner as to become subject,;tolworkman's compensation taws of California." Contractor's hiring or sub contracting signature <br /> Thei'ai"' <br /> s the following: "I certify that in the performance of the work for which this.pwmit is issued, I shall employ persons subject to workman's compensa <br /> aws of California." <br /> pplicant m 1call for all require54ions. dra rng on reverse side. <br /> 7 <br /> Signed Title: Date: `�-- -� <br /> FO#i EPAT N7 USE ONLY <br /> Application Accepted by Dat ~ AraA <br /> I Pit r Grout Inspection by Dated Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: Sen Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. <br /> . EH 13-241REV.i/nsi <br /> EH 74.26,'= b <br /> s. <br /> i <br />