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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION l <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> ,RERMIT 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. / f ^ ,, <br /> fJ �1 wl � C- ' VL r Lot Size/Acres e <br /> Job Address _ City 8 <br /> L �c d <br /> Owner's Name L 6 qi/ e 44- Address 1 C'`��! M A-,�Te-Ph =2 Lf? <br /> Conraclor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Oia. of Well Casing i <br /> N Domestic/Private ❑ Gravel Pack CJ Tracy Type of Casing Specifications <br /> Cl Public is Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —,Approx. Depth I i Eastern Surface Seal installed by <br /> L Repair Work Done ❑ Type of Pump H.P. State Work Done Q <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION t I DESTRUCTION i I INo septic system permitted if public sewer is <br /> available within 200 feet.I <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: ' <br /> CIA of �—e Water table depth <br /> SEPTIC TANK. f9"_Type/Mf9 "� �® L✓��� Capacity 0'0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disppsal be 04'" <br /> Distance to nearest: Well 6-9 01 'e'Foundation�� Property Line J.d <br /> ` l <br /> LEACHING LINE Cl No. & Length of lines TPtal length/size <br /> FILTER BEE Distance to neatest: WeW Foundation .D Property Line <br /> Cif `r DAC <br /> SEEPAGE PITS l I Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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 <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 follow' : "I certify the in the or nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cali r la." <br /> The applicant us call for all re ired c s. Complete drawing on reverse side. <br /> Signed Title: OCOOfl F.[�, Date: <br /> F R DEPAPeMENT USE ONLY <br /> Application Accepted by Date ea <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: l <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services i <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT Aima TED � RECEIVED BY DATE PERMITNO. <br /> . EH13.24IREV.IIK51 { �j <br />