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APPLICATION FOR PERMIT <br /> j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION UUU <br /> 11d15 AA Sa-i 70494:V • , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> OWIT 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 /> i 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 &Q6 k,2eA Z4 1sDw1 ljJA City O Lot Size/Acreage <br /> r / A I ' LcJ I! 65 ' <br /> Owner's Nam@16046 at .v r�dl iScs- �s Address � .c,Es �i� y_,�.i. 4e6g&Ph°ne .3G <br /> Contra r�p(Nic �'�UiI. ��rs. Address / r TP License No. PhonrQ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER IlliOuMo itoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PR�0s Surf <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> iNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public Cl Other I n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _,Approx.IDepth f 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 It Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is <br /> I available within 200 feet.i <br /> _" <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 C <br /> SEPTIC TANK. O Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0Method of Disposal <br /> Distance to <br /> nearest: Well Foundation Property Line <br /> LEACHING LINE D 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 tri nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 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 i <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 Caiifo - � r N „ � � <br /> The applicant st call or required in cti ns. Complete drawing on rover e. <br /> Signed Title: at' <br /> /lji r f <br /> ate: <br /> FOR DEPARTMENT US ONLY <br /> Application Accepted by Date A50 Area _ <br /> Pit or Grout Inspection by X Date Final Inspection by Date <br /> Additional Comments: <br /> i <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 /> FEE <br /> INFO AMOUNT DUE I � AMOUNT REMITTED K R RECOED ED BY DATE PERMIT No. <br /> . EMA-21iREv.rinSl Y""j 2�1R� <br /> EH:3-2a <br />