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I , 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 /> PERMIT EXPIRES 1 YEAR FROM-- DATE ISSUED <br /> (Completer 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 IUM broge /Ploac) City__9<6Q Lot Size/Acreage <br /> La cru D 9 SLI I fgr7 Phone 1(39-9 ) <br /> Owner's Nam,�ye, p � Address � �t <br /> Contractor M r IuW A�®dress S r` d Da�`�a3f� - Phone `d I <br /> License No. <br /> TYPE OF WELL/PUMP: NEW WELL %1, WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION IL SYSTEM REPAIR D OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES. DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI& .SPECIFICATIONS 4 <br /> C-1 Industrial ❑ Open Bottom--E)—Manteca---o---Q well Excavation Dia. of Well Casing S <br /> N,Domestic/Private [Gravel Pack D Tracy Type of Casing Specifications <br /> I'1 Public CI Other n Delta Depth of.Grout Seal f I)r? I Type of Grout,R�n� <br /> I I trri0ation Approx. Depth` '1I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump Sub,J_ H.P. S State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION 1 1, DESTRUCTION t I (No septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> Installation will serve: Residence___._ Commercial,_-..Other-_ available <br /> Number of living units: Number of bedrodms x <br /> Character of soil to a depth of 3 feet: C "r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ a# I" Method of Disposal <br /> r Distance to nearest: Well - Foundation Property Line <br /> LEACHING LINE ❑ No. & LengtKof lines ` }`:�� Total length/size <br /> FILTER}SED ❑ Distance to nearest: k Well Foundation Property Line F <br /> SEEPAGE PITS 11 Depth 1 Size t'- ` Number t <br /> SUMPS �y LI Distance to nearest: I.Well Foundation Property'Line r <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I_have prepared this application and'ffiai rhe 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 r <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 California." <br /> The applicant ca o al required inspections. Complete d►a ing on reverse side, <br /> Signed `` ilia: Date: ..� <br /> O DEPARTMENT USE ONLY l <br /> Application Accepted by Date -' Area <br /> Pit o rout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> Applicant — Return all copies to: San J Cin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> �� # <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24 IREV,r i n al <br /> EH A-2EO�� <br />