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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 0 BOX 2009, STOCKTON, CA 95201 <br /> 2W-WIT EXP_RES 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 22aCity Lot Size/Acreage <br /> Owner's Name ddmrm Phone <br /> Contractor S dress G4 License No. Phone <br /> TYPE OF WELL/PUMP: NEVV 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 /> FGUNOATION-- •��. ..AGRICULTURE:WELL- —OTHEft WELL .-P-IISI-SOAPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rt ,,��,, J{ <br /> C1 Industrial jj CrtSpen Bottom ❑ Manteca Dia. of Well 6 ZG�S�dia of Well Casing <br /> _tri ' <br /> ' <br /> Domestic/Private' '1 Gravef Pack ❑ Tracy Type of Casing Specifications <br /> f"1 Public ? OlheA } fl Delta Depth of GroutSeal Type of Grout 157 Tr&.1it <br /> I ) Irrigation 21OApprox, Depth , II I Eastern Su ce Seal Installed by <br /> Repair Work Done �—Type.-of-Rump—:(� H.P. � 9 to ork Done Qn1 A dGE�C,L. �i O11't <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth_ -7—,02 <br /> Filler Material & Depth T� 7—`�� <br /> Detptn p Pl/JYI CBitlj�t <br /> TYPE OF SEPTIC WORK"°-NEWVNSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> _1 available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of livirild-units: Number of bedrooms I <br /> - <br /> =� <br /> Character of soil'tb,��depth of 3 feet, �����!_- 4Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ '# ` � \ Method of Disposal <br /> tanC6 r�tearest: Well Foundation Property Line <br /> LEACHING LINE-ti`s` ❑,�No.'&�Lengft�of lines _ _ _ Total lanpth/size <br /> FILTER BED ,[_l Distance to nearest: Well Foundation �. Property Line <br /> �.V <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line ; <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt 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 cenifies the following: "I certify that in the performance o.f the w67klfor which this permit is issued, 1 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'tirnploy persons subject to workman's compensa- <br /> tion taws of Celifoinia" _ I <br /> The applicant i us ✓ ired Complete drawing on revergcide. <br /> Signed t Title: l///! -�~ Date: 0 -7 <br /> f F f r F DEPARTMENT USE 6NILY I <br /> Application Accep;by . data -_tom c�-�_C'1 i� Area <br /> J' <br /> Pit or Grout Inapecti2i y _r' _ Date Final Inspection by-5 ca ' Date <br /> I <br /> Additional Comments: ' <br /> Applicant -'Return all copies to: San Joaquin County Public Health <br /> ------� -------------------�---- Services,-JFnvi:Fo®entai-iieaJ:th'Peratit"/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> _me . - OUNT DUE hANIbUNT REMITTED-I% -C SH jC % RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.i/M 5) <br /> E14.14-20 C'd.. —_------- <br />