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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 /> PPXMIT 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin CountyPublicHealth Services. <br /> Job Address f/e0-?/ Al - 'T� -- -- - City LOP f Lot Size/Acreage �^J�O7�y <br /> Owner's Name Address �^y Phone F/ O <br /> Contractor, - Address License No s7z/ Phone 4dr <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: Si01C TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"I Public Ci Other 0 Delta Depth of Grout Sea! Type of Grout <br /> I I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done r <br /> Well Destruction 0 Well Diameter Sealing Material & Depth > <br /> Depth Filler Material & Depth `0. .. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ro REPAIR/ADDITION I 1 DESTRUCTION ( I INo septic system permitted if public sewer is <br /> I <br /> available within 200 feefJ p_ <br /> e �] <br /> Installation will serve: Residence+ Commercial— Other - -- - <br /> Number of living units: ,.,..L_ Number 91 bedrooms -� t o <br /> Character of soil to a depth of 3 feet: Water table depth PLO f <br /> SEPTIC TANK. C]''-Type/Mfg Capacity No. Compartments 2 - <br /> PKG.,TREATMENT PLT. 0 - Method of Disposal <br /> Distance to nearest: Well_1106!{Foundation _ __ ro { Property Line j <br /> LJ <br /> LEACHING LINE C4-'^-No, & Length of lines 63 A2,r Total length/size 2�� r � V( <br /> FILTER BED CI Distance to nearest: Well 192M inundation'a s Property Line t w <br /> SEEPAGE PITS I"4rDepth .�b� 5i re uI Number <br /> 1 { f <br /> SUMPS r Ll Distance to nearest: Well Foundation�- Property Line <br /> DISPOSAL PONDS o <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 1 <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 shallnot <br /> employ any parson 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 applectnt m t call for all requi d inspJ1.ctions. Complete drawing on reverse side. <br /> c <br /> Signed X Title: eowAx& Date: 1__2 <br /> FOR DEPARTMENT USE ONLY <br /> p tion Accepted by�� Data eZ Area 12 -_ <br /> Pit or rout Inspection by DatS -�' Final Inspection by ; Dat <br /> Additional Comments: <br /> Applicant - Return all copies to: Sae Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUN/T�DUE AMOUNT REMITTED CASH RE I ED BY DATE PERMIT'N0. <br /> « EH 14.2 1REV.�in5 �c./ //I1 00) iJ� <br />