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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 O BOX 2009, STOCKTON, CA 95201 <br /> I <br /> PERMIT EXPIRES 1 YEAR_FRQM.-DATE 15SUED <br /> (Complete in Triplicate) j <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 'C City Lot Size/Acreage <br /> [� <br /> Owner's Name �rn A ltk h-- - Address 70 ��� �� - Phone <br /> Address rry� License No;`3 lSZ- Phone 72_%WContractor <br /> _ <br /> " TYPE OF WELL/PUMP: .NEW WELL ❑ .. . WELL REPLACEMENTF °""`DESTRUCTIO -Out_of,Service Well 0 <br /> PUMP-INSTALLATION El _T SYSTEM REPAIR ❑ —--OTHER-0 , Monitoring Well" C7 { <br /> DISTANCE TO-NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL`FLD. PROP.•LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> 17 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I i irrigation �.Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work,Done ❑ Type of Pump H.P. State rk D e_ _ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth ; p <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic sysigM permitted it public sewer is ; <br /> available wit ' 200 feet.) <br /> � I <br /> installation will serve: Residence Commercial— Other <br /> Number of living units: Numbe bedrooms , <br /> Character of soil to a depth of 3 feet- Water table depth <br /> SEPTIC rTANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundatio Property Line <br /> LEACHING LINE ❑ No. & Length of lines I Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation RProperty Line <br /> SEEPAGE PITS 11 Depth Num <br /> SUMPS Ll Distance to nearest: Well Foundat n Pro Line <br /> DISPOSAL PONDS ❑ w <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 foilowing: "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 subcontracting 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 Califo la.,' <br /> The applicant m ci tions. Complete drawing on reverse side. .` <br /> Signed X Title: -__-� � �� Date' I <br /> y OR DEPARTMENT USE ONLY 7'r <br /> Application Accepted by Date �! v Area ? L <br /> Pit or Grout Inspection by Date Fins Inspection by Date <br /> Additional Comments: <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 `r <br /> 4 <br /> IFEE <br /> AMOUNT DUE AMOUNT REMITTED CASH CK d RECEIVED BY OAiTE PERMIT'N0. <br /> EH 13-241t1EV.i/Hsl <br /> EH 14.28 CV/ <br /> f <br />