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} <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> PHONE (209)46$--3420 <br /> P O BOX 2009, STOCKTON, CA 9520x-.-? <br /> MUMIT I <br /> 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Dom, /� City,� Lot Size/Acreage <br /> oori <br /> OwnerAo"I's Nametf��lr'efi ,t/fC/i//eiSreC-�t/Ets*Address� �tSJr �iG�,.,f_ �!(i�s/ phon / X D <br /> / I q <br /> Contractor Zg ess 11•�aL cense C-S�Jlts-sYq Phon"?-,z8 O <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p J Monitoring Wellg <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> l NDED-USE- "TYPE-OF-'WECL PROBLEM AREA"CONSTRUCTION 5PECIFICATIQNS <br /> Industrial ❑ O0 'e Bottom ❑ Manteca Dia. of Well Excavation DiaC7 . of Well Casing d <br /> II 11 Domestic/Private ;Gravel Pack Tracy Type of Casin ` _ <br /> �L.-��"�� Specifications..� <br /> I"I Public 171 Other hl Delta Depth of Grout Seal ` Type of Grou I;/,— <br /> i I Irrigation 'Approx. {Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pumpi -0" H.P. State Work Done <br /> Well Destruction O Well Diameters ` Sealing Material & Depth & <br /> Depth �J Filler Material & Depth __-_.A//,} <br /> TYPE OF SEPTIC WORK; NEW INSTALLATfON I I REPAIR/ADDITION I I DESTRUCTION I 1 iNo 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 Solt to a depth of 3 feet: + Water table depth Q <br /> SEPTIC TANK ❑ Type/Mfg, Capacity_ -- R No. Compartments <br /> PKG. TREATMENT PLT.. Cl -1 <br /> Method of Disposal <br /> Distance to�nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ` <br /> FILTER BED ❑ Distance toinearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance toynearest: Well Foundation Property Line ` <br /> DISPOSAL PONDS 0 <br /> I_hereby,certify that I have_prepared_this-application-and_that-the-work will be done in accordance with San Joaquin county ordinance-c-statiriale s-, aril - <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 <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: "t certify that in the performance of the work for which this permit is is d, I sha11 employ persons subject to workman's compensa- <br /> tion laws of Ca' nia." p <br /> The applica must call to all re uin 'ns tions. Complete drawing on rev side. <br /> Signed Title: <br /> FOR QEPARTMENT SE ONLY <br /> Application Accepted by <br /> Date Ares <br /> Pit or Grout Inspection by Date Final Inspection by Date 43 <br /> Additional Comments: <br /> Applicant - Return all copies to: ISan Joaquin County Public Health <br /> 'Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE l' �' AM UNT REMIMD CK RE I ED 8Y DATE PERMIT NO. <br /> INFO <br /> 14-20 <br /> *.EH 13-21 tR£v.r/1s5J <br />