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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 /> 2HRMIT EXPIRES_ 1 YEAR FM DATE ISSUED <br /> (Cbmplete 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 aad Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Z-26 _,.X City Z' C3At/ Lot Size/Acreage /6 <br /> � <br /> Owner's-Name Z r Address c Phone <br /> , <br /> Contractor y I,�/ �-�/_4G4 L Address J License No,52; TT5_1�� Phone �S <br /> TYPE OF WELL/PUMP:, r,NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑jOpen 136ttom ❑ Manteca Dia. oQWell E'cavation Dia. of Well Casing° I <br /> F Domestic/Private D) Gravel Pack D Tracy Type of Casing Specifications- - I <br /> I'I Public 1-1`Other r n Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation .Approx. Depth I I Eastern Surface Seat 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__ � _- ;Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION X %'REP•AkRlA0OITION ( I DESTRUCTION l I (No septic system permitted if public sewer is <br /> K ' available within 200 feet.) 1 <br /> Installation will,serve: Residence 1 Commercial- Other -...... <br /> Number of livingunits: //'� <br /> _-_L.1— Nurtiber of bedrooms , <br /> Character of soil to a depthjof 3 feet: ! Water iable'depth <br /> SEPTIC TANK. ❑ Yype/Mfg Gapacity_Z_60V Nd. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal �J <br /> i �, 4 r <br /> /GD�`F r'' `fes' ' <br /> Distance`to nearest: 1 Well Foundation PropertyLine ___ <br /> LEACHING LINE iNo. & Lilngth of lines?" - �tl-- Total length/size <br /> FILTER BED n ,`Distance'to nearest: Wall '/%Foundation `' A15— Property Line <br /> SEEPAGE PITS ;Depth i iY'� __- Size !/ ,�'-'_ 4umber _ <br /> SUMPS 0 bistance'to nearest: Well Foundation„ Property Line J ` <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thisapplication and that the work will be done in accordance with San Joaquin county ordinances,'stata 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 of sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for whish this pertnit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> e- —. <br /> The applicant must call for 0'required inspections. Complete drawino on,reVefse-s de, <br /> Signed <br /> I DE. TM_ENT USE ONLY <br /> Application Accepted by Date I� as <br /> i <br /> Pit r Grout Inspection b Date Final Inspection by Date <br /> Additional Comments: t ` <br /> Applicant - Return all copies to:' San Joaquin County Publi'c;,Health i <br /> ' Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA "95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'NO. <br /> r CASH ) <br /> . EH13.24(REV.L/H5) <br /> EH 44-20 <br /> . A � <br />