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-�° APPLICATION FOR PERMIT <br /> 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 /> PEMIT EXPIRES 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 compliance with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /} / <br /> Job Address 7 l[/O � �!!`� _______.__ City ZOA Lot Size/Acreage <br /> Owner's Name :Y-o . �L� Address / 1 Phone <br /> Contractor Address License No. 7 73 Phone33�L • Z <br /> TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION C] Out of Service Well ❑ i <br /> PUMP INSTALLATIOhOC SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C3 <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 /> Q F] Industrial ❑ Open Bottom ❑ Manteca Dia. of Welk Excavation�,� Dia. of Well Casing <br /> )f�_YDomestic/Private Gravel Pack 0 Tracy Type of Casing 104'G Specifications- - <br /> F1 Public-_ is Other n Delta Depth of Grout Seal Type of Grnut C<A11-ek4 <br /> I I Irrigation N, Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction �' ❑ Well Diameter Sealing Material & Depth <br /> :,, Depth Filler Material & Depth l 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial___,_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ElType/Mfg > Capacity Na. Compartments ? <br /> PKG. TREATMENT PLT. ❑ ° Method of Disposal <br /> Distance to nearest: Well ~ Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines -Total length/size i <br /> FILTER BED C] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L3 Distance to nearest: Well Foundation . __.,,___. Property Line [� t <br /> DISPOSAL PONDS ❑ d <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 /> 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 call for all required inspections. Complete drawing on reverse side. <br /> Signed X ATG Title: __ C � _ _ Date: <br /> :FOR:DEP TMENT USE ONLY <br /> 6 <br /> App'cation ccepted by Date [1 r 2 2 Area r <br /> orGrout spection by Date a Final Inspection by--� rV� k� Date IV-30_�7( <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health ) <br /> rI <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 CK� CASH RECEIVED By DATE PERMIT N0. <br /> Eli A-?e 24 IREV. 15 7S <br /> EH i�� I/n5i �V� v"l [ V ,J -2-2j,) <br /> �'VW�� U-25 <br />